Dysfunction of the biliary tract in children treatment. Pathology of the biliary tract: biliary dyskinesia. Laboratory and instrumental diagnostics

A.A. Ilchenko

Central Research Institute of Gastroenterology, Moscow.

In the last decade, both in Russia and abroad, despite certain successes in therapy associated with the appearance on the pharmaceutical market of new effective drugs for the correction of functional disorders of the digestive system, there has been no decrease in the number of functional diseases of the biliary system. The prevalence of functional disorders of the biliary tract, according to various estimates, ranges from 12% to 58%. Moreover, among women they occur 2-3 times more often than among men.

Functional disorders of the gallbladder and sphincter apparatus of the biliary tract are characterized by spontaneity and a variety of clinical manifestations, the duration of the course, and the complexity of diagnosis, which ultimately leads to a high appeal of patients for medical care. At the same time, a long and unsuccessful search for a somatic or neurological disease contributes to the formation of hypochondria, depressive disorders, and exacerbates the patient's poor health. Late diagnosis and inadequate therapy can significantly impair the quality of life of such patients, form a stable opinion in patients about the presence of a severe and incurable disease, and force patients to follow a diet for a long time.

A long-term pain syndrome that systematically brings suffering to the patient can cause depressive disorders. Depression that joins pain worsens pain tolerance, intensifies it and is one of the factors contributing to its chronicity. Currently, functional diseases of the biliary tract are usually considered as a manifestation of a general neurosis. However, this does not exclude the possibility of their occurrence as viscero-visceral reflexes, caused both by the pathology of the digestive organs and diseases of other organs and systems.

From a clinical point of view, functional disorders of the biliary tract are of particular interest, as they contribute to the formation and progression of a number of organic diseases. First of all, this concerns the pathology associated with the addition of an inflammatory process in the biliary tract and a violation of the colloidal properties of bile, which may ultimately require the use of surgical methods of treatment.

Dysfunctions of the biliary tract are one of the essential factors involved in the formation of biliary lithogenesis, especially at its initial stages. In this regard, early diagnosis and adequate therapy of functional disorders of the gallbladder and the sphincter apparatus of the biliary tract are an important clinical task.

Currently, in accordance with the Rome Consensus (Rome, 1999), functional diseases of the digestive tract are usually defined as complexes of constantly or periodically occurring clinical symptoms from various organs of the digestive system, unexplained by structural or biochemical reasons.

In relation to the biliary tract, functional diseases of the biliary tract can be defined as a complex of clinical symptoms that have developed as a result of motor-tonic dysfunctions of the gallbladder and the sphincter apparatus of the biliary tract.

Regardless of the etiology of dysfunction, the main goal of therapy for functional disorders of the biliary tract is to restore normal bile flows in the extrahepatic biliary tract and its timely outflow into the duodenum.

In most cases, patients with dysfunction of the biliary system can be treated on an outpatient basis. However, with polymorphism of complaints, conflict situations at home or at work, difficulties in differential diagnosis with other diseases of the biliary system, requiring the use of complex research methods, hospitalization in a therapeutic hospital for a period of 10-14 days is advisable.

In the presence of neurotic disorders, the use of sedatives or tonics, drugs that normalize sleep is indicated. It is important to contact the doctor with the patient with an explanation of the causes of the disease and possible ways to eliminate them. If necessary, a consultation with a psychotherapist is appointed.

Diet therapy occupies an important place in the treatment of patients with functional diseases of the biliary system, since proper nutrition, taking into account the nature of motor disorders, contributes to faster rehabilitation of patients and improves the quality of life. A diet with frequent meals of small amounts of food (5-6 meals a day) is recommended, which leads to regular emptying of the gallbladder, normalizes pressure in the ductal system of the biliary tract and duodenum. Patients are allowed a late meal shortly before bedtime.

Alcoholic drinks, carbonated water, smoked, fatty and fried foods, as well as seasonings are excluded from the diet, as they can cause a spasm of the sphincter of Oddi. In the diet, it is necessary to take into account the influence of individual nutrients on the motor function of the gallbladder and biliary tract. So, with a hyperkinetic type of dysfunction, products that stimulate contractions of the gallbladder should be sharply limited - animal fats, vegetable oils, rich meat, fish, mushroom broths. The use of products containing magnesium is shown, which reduces the tone of smooth muscles (buckwheat, millet, wheat bran, cabbage). The use of egg yolks, muffins, creams, nuts, strong coffee and tea is excluded or limited.

With a hypokinetic type of gallbladder dysfunction, patients usually tolerate weak meat broths, fish soup, cream, sour cream, vegetable oils, soft-boiled eggs. Vegetable oil is prescribed one teaspoon 2-3 times a day half an hour before meals for 2-3 weeks. To prevent constipation, it is recommended to use foods that promote bowel movement (carrots, beets, pumpkins, zucchini, greens, watermelons, melons, prunes, dried apricots, oranges, pears, honey). Bran has a pronounced effect on the motility of the biliary tract.

Biliary dysfunction may be accompanied by psycho-emotional disorders, signs of endogenous depression. Depending on psycho-emotional, neurovegetative disorders, drugs that normalize the psychosomatic status are differentially used: adaptogens, sedatives, tranquilizers, antidepressants, neuroleptics, ganglionic blockers, physiotherapy, physiotherapy exercises, etc. In recent years, antidepressants are increasingly used to correct visceral hyperalgesia in functional gastrointestinal disorders and violations of the motor-evacuation function of the gallbladder. Among antipsychotics, sulpiride deserves attention. The drug, due to the blockade of dopamine D2 receptors, has an antiemetic and normalizing effect on the motility of the gastrointestinal tract. It is prescribed with caution to the elderly, as this category of patients often has an increased sensitivity to sulpiride.

Clinical manifestations in dysfunctions of the biliary tract are due to both violations of humoral and nervous regulation in the sympathetic and parasympathetic divisions of the autonomic nervous system. To correct autonomic regulation, various vegetotropic preparations are used. In practical terms, the appointment of -blockers (propranolol, etc.), which have a mixed (peripheral and, to a lesser extent, central) effect, drugs of central and peripheral -adrenergic blocking action (pyrroxane), as well as combined drugs with anticholinergic and  -adrenergic blocking action (belloid, bellataminal, bellaspon). Ganglioblockers (gangleron, etc.) can be used for secondary biliary dysfunction in patients with chronic cholecystitis with developing right-sided reactive vegetative syndrome due to chronic irritation of the sympathetic structures of the autonomic nervous system, as well as with the appearance of various viscero-visceral pathological reflexes, in particular, with cholecysto -cardiac syndrome and reflex angina pectoris.

In autonomic disorders, accompanied by signs of increased neuromuscular excitability, the appointment of mineral correctors (preparations containing calcium, magnesium, vitamin D2) is indicated. Acupuncture, laser therapy, hydrotherapy, hypnosis sessions, special complexes of physiotherapy exercises and breathing exercises are effective.

With dysfunction caused by an increase in the tone of the sphincters of the biliary system, antispasmodics are used. As antispasmodics, both non-selective (methacin, platifillin, baralgin, etc.) and selective M1 anticholinergics (gastrocepin) are used. However, it should be borne in mind that when taking this group of drugs, a number of side effects can be observed: dry mouth, urinary retention, blurred vision, tachycardia, constipation, drowsiness. The combination of relatively low therapeutic efficacy of this group of drugs with a wide range of side effects limits their use, especially in the treatment of sphincter of Oddi dysfunction. From myotropic antispasmodics, drotaverine, benciclane, mebeverine, otilonium citrate, trimebutine or gimecromone are used, which has a selective antispasmodic effect on the sphincter of Oddi. The latter is prescribed half an hour before meals, 200-400 mg (table 1-2) 3 times a day. The course of treatment is 1-3 weeks. Due to the choleretic effect of the drug, with its prolonged use, diarrhea may develop.

The drugs of the above groups have mainly an antispasmodic effect and do not affect the nature of pathological changes in the liver.

In this regard, Gepabene deserves attention - a combined preparation of plant origin, consisting of an extract of fumes and an extract of milk thistle fruits. Gepabene is taken after meals 1 capsule 3 times a day. The dose may be increased up to 6 capsules per day (2 capsules 3 times a day). For night pain, you can also take 1 capsule at bedtime.

The drug is indicated both for primary dysfunction of the sphincter apparatus and the gallbladder, and for functional disorders accompanying liver pathology - fatty liver, chronic hepatitis and cirrhosis of the liver. The drug is indicated for dysfunction of the sphincter of Oddi, which developed after cholecystectomy and is accompanied by biliary insufficiency of I-II severity.

Recent studies have shown that Gepabene can be successfully used in individuals with chronic cholecystitis and various forms of biliary sludge, the formation of which is facilitated by functional disorders of the gallbladder and the sphincter apparatus of the biliary tract.

In case of gallbladder dysfunction caused by hypomotor dyskinesia, to increase contractile function, prokinetics are used for 10-14 days: domperidone 5-10 mg per day 3 times a day 30 minutes before meals or metoclopramide 5-10 mg per day. As cholecystokinetic agents, a solution of magnesium sulfate 10-25%, 1-2 tablespoons 3 times a day or a solution of sorbitol 10%, 50-100 ml 2-3 times a day, 30 minutes before meals or 1 hour after meals, is used.

A positive effect is exerted by agents that reduce duodenal hypertension and normalize the processes of digestion in the small intestine. In the presence of microbial contamination, the appointment of doxycycline 0.1 g 2 times, tetracycline 0.25 g 4 times, furozolidone 0.1 g 3 times, nifuroxazide 0.2 g 4 times, intetrix 1 caps. 4 times within 1-2 weeks. After antibiotic therapy, a two-week course of probiotics (bifiform, etc.) and prebiotics - Hilak-forte 40-60 drops 3 times a day before or during meals (after improvement in the condition, the daily dose can be reduced by 2 times) is necessary.

Physiotherapeutic procedures that are prescribed during the period of exacerbation subsiding effectively complement drug therapy. Thermal procedures (paraffin, ozocerite), as well as UHF, UHF-therapy, ultrasound are shown. Various methods of reflexology are used (needle and laser therapy). In the treatment of autonomic disorders underlying pathological disorders in the biliary system, accompanied by increased emotional excitability and lability, irritability, the appearance of anxiety, fear, exhaustion of the nervous system, the effectiveness of acupuncture and laser puncture is almost the same. For patients with increased irritability and emotional instability, laser puncture is more acceptable, due to the painlessness of the procedures.

The main criteria for evaluating the effectiveness of therapeutic measures for functional disorders of the biliary tract:

Relief of clinical symptoms;

Restoration of the motor function of the gallbladder;

Restoration of the tone of the sphincter apparatus of the biliary tract;

Restoration of pressure in the duodenum.

Drugs with different, and sometimes with a combined mechanism of action, make it possible to choose a more adequate therapy that can significantly improve the well-being and quality of life of patients with functional disorders of the biliary tract.

Literature:
1. Ilchenko A.A., Orlova Yu.N. Gepabene use in patients with chronic cholecystitis. Materials of the 3rd Russian Scientific Forum "St. Petersburg - Gastro-2001". Gastro Bulletin No. 2-3. 2001, p. 39.
2. Vikhrova T.V. Biliary sludge and its clinical significance. Diss. cand. honey. Sciences. M.: 2003. 115 p.
3. Nemtsov L.M. Dysmotility of the gallbladder in biliary pathology (clinical and pathophysiological characteristics and correction). Vitebsk: VSMU, 2004. 183 p.
4. Maev I.V., Samsonov A.A., Salova L.M. and other Diagnosis and treatment of diseases of the bile ducts. Tutorial. M.: GOU VUNMTs MZ RF, 2003. 96 p.
5. Ilchenko A.A. Cholelithiasis. M.: "Anacharsis", 2004. 200 p.
6. Mertz H., Fass R., Kodner A., et al. Effect of amitriptyllini on symptoms, sleep, and visceral perception in patients with functional dyspepsia. Am. J. Gastroenterol. -1998. -Vol.93. -p.237-243.
7. Fioramonti J., Bueno L. Centrally acting agents and visceral sensitivity. gut. - 2002. -Vol.51(Suppl 1). p. 91-95.

A.A. Ilchenko, Central Research Institute of Gastroenterology, Moscow

The close anatomical and functional relationship of the digestive organs, on the one hand, causes a wide spread of functional disorders in various diseases, including biliary pathology, on the other hand, is the cause of the diversity of clinical symptoms, which in certain situations can create significant diagnostic difficulties.

According to the latest international classification, instead of the term "functional diseases of the biliary tract" (Rome Consensus, 1999), the term " dysfunctional disorders of the biliary tract". Regardless of the etiology, two types of disorders are distinguished: gallbladder dysfunction and sphincter of Oddi dysfunction. In the International Classification of Diseases (ICD-10), heading K82.8 includes "Dyskinesia of the cystic duct or gallbladder", and heading K83.4 - " spasm of the sphincter of Oddi.

The nature of functional disorders and the variety of clinical symptoms are associated both with the complexity of the anatomical structure of this part of the digestive system and with the features of neurohumoral regulation.

Biliary tract is a complex system of bile excretion, including an extensive network of small intrahepatic bile ducts, larger extrahepatic ducts, which subsequently form the right and left hepatic ducts, and the latter merge into the common hepatic duct.

The gallbladder with the sphincter of Lutkens and the cystic duct is an extremely important anatomical structure that plays a leading role in the formation of both functional and organic pathology of this section of the biliary tract. As a result of the confluence of the common hepatic duct with the cystic one, the common bile duct is formed, which ends with the biliary-pancreatic ampulla with the sphincter of Oddi. The latter consists of the sphincter of the common bile duct, the sphincter of the pancreatic duct, and the common sphincter of the ampulla (Westphal sphincter).

The process of bile formation goes on continuously, and the daily flow rate of bile averages 800-1500 ml, and the flow of bile occurs only during the meal. Hence, the important role of the gallbladder and the entire sphincter apparatus of the biliary tract in ensuring the normal functioning of the digestive processes is obvious.

At each meal, the gallbladder contracts 1-2 times, while bile enters the lumen of the small intestine, where, together with other enzymes, it participates in digestion. The gallbladder on an empty stomach contains about 30 - 80 ml of concentrated bile, but with stagnation, its amount can increase significantly. This is due to the fact that the wall of the gallbladder contains elastic fibers and in biliary hypertension its volume can reach 100-150 ml. In women, the gallbladder in a state of functional rest has a slightly larger volume than in men, but it contracts faster. With age, the contractile function of the gallbladder decreases.

The regulation of the motor activity of the biliary system involves the parasympathetic and sympathetic divisions of the autonomic nervous system, as well as the endocrine system, which provide a synchronized sequence of contraction and relaxation of the gallbladder and sphincter apparatus. Gastrointestinal hormones (cholecystokinin-pancreozymin, gastrin, secretin, motilin, glucagon) play the leading role in the regulation of the processes of the biliary system. intestines, to a lesser extent in the mucous membranes of the jejunum and ileum. CCK-PZ also stimulates the secretory function of the pancreas. Along with the contraction of the gallbladder, CCK-PZ helps to relax the sphincter of Oddi. It has little effect on the muscle fibers of the common bile duct. In a healthy person, CCK-PZ leads to a decrease in the volume of the gallbladder by 30-80% (food high in fat reduces the volume of the gallbladder by up to 80%). Various surgical interventions (cholecystectomy, vagotomy, resection of the stomach) cause significant dysfunction of the biliary system.

Normally, bile enters the intestine only during digestion. This is ensured by the reservoir function of the gallbladder and its rhythmic contractions with consistent relaxation of the sphincters of Lutkens and Oddi. The relaxation of the gallbladder is accompanied by the closure of the sphincter of Oddi.

Synchronicity disorders in the work of the gallbladder and sphincter apparatus underlie the dysfunction of the biliary tract and are the cause of the formation of clinical symptoms.

Dysfunctions of the biliary tract, depending on the cause that caused them, are divided into primary and secondary. Primary dysfunction of the gallbladder and the sphincter of Oddi, occurring independently, are relatively rare - an average of 10 - 15% of cases.

Much more often they are a concomitant symptom of other diseases of the digestive system: pancreas, stomach and duodenum or intestines.

Secondary dysfunctions of the biliary tract can be observed with hormonal disorders, treatment with somatostatin, with premenstrual tension syndrome, pregnancy, systemic diseases: diabetes, gluten enteropathy, hepatitis and cirrhosis of the liver, myotonia, as well as in the presence of inflammation and gallstones.

It should be noted that dysfunction of the biliary tract is one of the essential factors involved in the formation of biliary lithogenesis, especially at its initial stages.

The leading role in the occurrence of dysfunctional disorders of the biliary tract belongs to psychoemotional factors: psychoemotional overload, stressful situations. Dysfunction of the gallbladder and sphincter of Oddi may be a manifestation of a general neurosis.

An imbalance between the production of cholecystokinin, secretin and other neuropeptides has a certain effect on the contractile function of the gallbladder and the sphincter apparatus. Insufficient formation of thyroidin, oxytocin, corticosteroid and sex hormones also leads to a decrease in the muscle tone of the gallbladder and functional disorders of the sphincter apparatus.

After cholecystectomy in 70 - 80% of cases, various motor disorders of the biliary tract are observed. For the majority of patients who underwent cholecystectomy, insufficiency of the sphincter of Oddi with a continuous flow of bile into the lumen of the duodenum is characteristic; its spasm is less often noted.

After vagotomy in the first 6 months. there is marked hypotension of the biliary tract, gallbladder and sphincter of Oddi. Resection of the stomach with the exclusion of part of the stomach and duodenum from the act of digestion causes secretory and motor-evacuation disorders due to a decrease in the production of hormones, including CCK-PZ, motilin. The resulting functional disorders can become permanent and, in the presence of lithogenic bile, contribute to the rapid formation of gallstones.

Clinic

Dysfunctions of the biliary system are found mainly in women, mostly young, malnourished, asthenic physique, with an emotionally labile psyche.

Clinical symptoms consist of local and general symptoms. The general state, as a rule, does not change.

In the hyperkinetic form of gallbladder dysfunction and/or hypertonic form of sphincter of Oddi dysfunction, colicky pains periodically appear in the right hypochondrium radiating to the back, under the right shoulder blade, to the right shoulder, less often to the epigastric region, the heart. Pain is aggravated with deep inspiration, for a short time and usually occurs after an error in diet, cold drinks, physical activity, stressful situations, sometimes at night. In some cases, the cause of the pain cannot be established.

Common symptoms include irritability, fatigue, sweating, headaches, tachycardia and other neurotic symptoms.

With hypokinetic and hypotonic dysfunctions of the biliary tract, dull pains appear in the right hypochondrium, a feeling of pressure, fullness, aggravated after eating, when the torso is tilted. Common symptoms are dyspeptic disorders in the form of nausea, bitterness in the mouth, as well as bloating and constipation. Palpation can reveal moderate pain in the projection of the gallbladder (the intersection of the outer edge of the right rectus abdominis muscle with the lower edge of the liver).

It should be noted that primary dysfunctions of the biliary tract can occur with unexpressed symptoms, and secondary dysfunctions of the gallbladder or the sphincter of Oddi usually have clinical signs of the underlying disease.

Diagnostics

Diagnosis of dysfunction of the gallbladder and sphincter of Oddi is based on the above clinical symptoms, ultrasound data and other research methods.

The polymorphism of the clinical symptoms of biliary tract dysfunction is so pronounced, especially in individuals with a predominance of neurotic symptoms, that the diagnosis of the disease can be a rather difficult problem. In such cases, the diagnosis is established on the basis of the exclusion of other diseases of the gallbladder and biliary tract.

Diagnostic tests for diseases of the biliary tract can be divided into 2 groups: screening and clarifying.

Screening methods:

functional tests of the liver, pancreatic enzymes in the blood and urine;
ultrasound examination (ultrasound);
esophagogastroduodenoscopy.

Refinement methods:

Ultrasound with an assessment of the functional state of the gallbladder and sphincter of Oddi;
endoscopic ultrasonography;
endoscopic retrograde cholangiopancreatography (ERCP) with intracholedocheal manometry;
dynamic cholescintigraphy;
drug tests with cholecystokinin or morphine.

In patients with primary dysfunction of the gallbladder, functional liver tests, the content of pancreatic enzymes in the blood and urine, and endoscopy data do not have significant deviations from the norm. With dysfunction of the sphincter of Oddi during or shortly after an attack, there may be a transient increase in the activity of aminotransferases and the level of pancreatic enzymes. In the case of functional disorders of the gallbladder and sphincter apparatus of the biliary tract, which are the result of pathological changes in the liver, the level and nature of the violation of liver function tests depends on the underlying disease.

One of the leading places in the diagnosis of dysfunctions of the biliary tract is occupied by ultrasound. To clarify the nature of dyskinetic disorders of the gallbladder with the help of ultrasound, its volume is examined on an empty stomach and after a choleretic breakfast. The motor-evacuation function of the gallbladder is considered normal if its volume by the 30th - 40th minute decreases by 1/3-1/2 of the original. As a choleretic breakfast, 20 g of sorbitol with 100 ml of water or intravenous administration of cholecystokinin at a dose of 20 mg/kg are used.

It should be noted that ultrasound is not always a sufficiently informative method to assess the functional state of the ductal system and the sphincter apparatus. The upper limit of normal for the diameter of the common bile duct is 0.6 cm, but usually the common bile duct has a much smaller diameter - an average of 0.28 ± 0.12 cm. In 95% of patients, the diameter of the normal common bile duct is 0.4 cm or less . Due to flatulence, pronounced subcutaneous fatty tissue, the common bile duct is not always visualized or fragmentary.

It is believed that with dysfunction of the sphincter of Oddi (its paradoxical reaction or prolonged spasm) after a choleretic breakfast, the diameter of the common bile duct increases. However, the complexity of such an interpretation should be noted due to the small diameter of the common bile duct, since minor fluctuations in its diameter can be extremely difficult to detect.

For differential diagnosis between dysfunction of the sphincter of Oddi and a mechanical obstruction in the distal part of the common bile duct, ERCP is used. Indirect signs of an increase in the tone of the sphincter of Oddi are the diameter of the common bile duct more than 10 mm and the delay of the contrast agent in it for more than 45 minutes. Dysfunction of the pancreatic duct is evidenced by the expansion of the latter by more than 5 mm and the slowing down of the evacuation of the contrast agent from its lumen. However, in some cases, ERCP is technically unfeasible; in addition, it is associated with radiation exposure and side effects due to the reaction to the introduction of a contrast agent.

Direct manometry of the sphincter of Oddi makes it possible to judge the presence of biliary hypertension, its degree and decide on the advisability of sphincterotomy. Manometric examination is performed using a special probe inserted during percutaneous transhepatic cannulation of the common bile duct or, most often, during ERCP. However, this method has not yet been widely used in clinical practice.

In recent years, to study the functional state of the biliary system, the method of dynamic cholescintigraphy has been widely used, based on selective absorption from the blood by hepatocytes and excretion of 99m Tc-labeled radiopharmaceuticals (RP) in the bile. The value of the method lies in the possibility of continuous long-term monitoring of the processes of radiopharmaceutical redistribution in the hepatobiliary system under physiological conditions, which makes it possible to indirectly judge the functional state of hepatocytes, quantify the evacuation capacity of the gallbladder, and also identify bile outflow disorders associated with both a mechanical obstruction in the biliary system, and spasm of the sphincter of Oddi.

Treatment

In most cases, patients with dysfunction of the biliary system can be treated on an outpatient basis. However, with polymorphism of complaints, conflict situations at home or at work, difficulties in conducting differential diagnosis with other diseases of the biliary system, hospitalization in a therapeutic hospital for 10-14 days is advisable.

In the presence of neurotic disorders, sedatives or tonics, drugs that normalize sleep are indicated.

diet therapy occupies an important place in the treatment of patients with dysfunction of the biliary system. The general principle of the diet is a diet with frequent meals of small amounts of food (5-6 meals a day), which contributes to the regular emptying of the gallbladder and ductal system. Alcoholic drinks, carbonated water, smoked, fatty and fried foods and seasonings are excluded from the diet, as they can cause a spasm of the sphincter of Oddi. In the diet, the influence of individual nutrients on the normalization of the motor function of the gallbladder and biliary tract is taken into account. So, with a hyperkinetic type of dysfunction, products that stimulate the contraction of the gallbladder should be sharply limited: animal fats, vegetable oils, rich meat, fish, mushroom broths.

With hypotension of the gallbladder, patients usually tolerate weak meat broths, fish soup, cream, sour cream, vegetable oils, soft-boiled eggs. Vegetable oil is prescribed one teaspoon 2-3 times a day for half an hour before meals for 2-3 weeks. To prevent constipation, products that promote bowel movement are recommended (carrots, pumpkin, zucchini, herbs, watermelons, melons, prunes, dried apricots, oranges, pears, honey). Bran has a pronounced effect on the motility of the biliary tract.

With dysfunction caused by an increase in the tone of the sphincters of the biliary system, antispasmodics, non-selective (methacin, platifillin, baralgin, etc.) selective M1-cholinergic blockers (gastrocepin) are prescribed. However, when taking this group of drugs, a number of side effects can be observed: dry mouth, urinary retention, blurred vision, tachycardia, constipation, drowsiness. The combination of rather low efficiency with a wide range of side effects limits the use of this group of drugs for sphincter of Oddi dysfunction. Of the myotropic antispasmodics, drotaverine (no-shpa, no-shpa forte), benziklan (galidor), mebeverine (duspatalin), otilonium citrate (meteospasmil), trimebutine (debridate) are used.

At present, the drug is widely used in clinical practice. hymecromon(odeston), which has a selective antispasmodic effect on the sphincter of Oddi and the sphincter of the gallbladder. Odeston is prescribed half an hour before meals, 200-400 mg (1-2 tablets) 3 times a day. The course of treatment is 1 - 3 weeks. With prolonged use, diarrhea may develop.

The drugs of these groups mainly have an antispasmodic effect and do not affect the nature of pathological changes in the liver.

In this regard, the drug hepabene deserves attention - a combined preparation of plant origin, consisting of an extract of fumes and an extract of milk thistle fruits.

Pharmaceutical fumes extract, containing the alkaloid fumarin, has a choleretic effect, normalizes the flow of secreted bile, and reduces the tone of the sphincter of Oddi.

Milk thistle fruit extract contains silymarin, a group of flavoid compounds that includes isomers: silibinin, silidianin and silychristin. Silymarin has a hepatoprotective effect: it binds free radicals in the liver tissue, has antioxidant membrane-stabilizing activity, stimulates protein synthesis, promotes hepatocyte regeneration, thus normalizing liver function in various acute and chronic diseases and functional disorders of the biliary tract.

Gepabene is taken after meals 1 capsule 3 times a day. The dose may be increased up to 6 capsules per day (2 capsules 3 times a day). For night pains, it is advisable to take an additional 1 capsule at bedtime.

Gepabene is indicated for primary dysfunction of the sphincter apparatus and gallbladder and for functional disorders accompanying liver pathology: fatty degeneration of the liver, chronic hepatitis and cirrhosis of the liver.

The drug is prescribed for postcholecystectomy syndrome, accompanied by dysfunction of the sphincter of Oddi and | or biliary insufficiency of I-II degree.

Recent studies have shown that hepabene can be prescribed to persons with various forms of biliary sludge, occurring both independently and developed against the background of gallbladder cholesterosis. Within 7-14 months, pain and dyspeptic syndrome stop in most patients, and with treatment from 1 to 2 months. in 60 - 100% of cases, biliary sludge disappears. This effect is due, on the one hand, to the ability of the drug to normalize the work of the sphincter apparatus of the biliary tract, and on the other hand, to the effect on the lithogenic properties of bile as a result of improving the function of the hepatocyte.

Studies conducted at the Central Research Institute of Gastroenterology (Yu.N. Orlova) found that after two weeks of taking hepabene 1 capsule 3 times a day in 75% of patients with hypokinesia of the gallbladder, the ejection fraction increased by an average of 6.7 ml.

In case of gallbladder dysfunction caused by hypomotor dyskinesia, prokinetics are used to increase contractile function for 10-14 days: ciprazide - 5-10 mg 3 times a day or domperidone - 5-10 mg a day 3 times a day for 30 minutes . before meals or metoclopramide - 5-10 mg per day. As cholecystokinetic agents, a 10-25% solution of magnesium sulfate is used, 1-2 tablespoons 3 times a day or a 10% solution of sorbitol, 50-100 ml 2-3 times a day for 30 minutes. before meals or 1 hour after meals.

Thus, the use of modern methods for diagnosing biliary tract dysfunction, taking into account the clinical features of the course of the disease, allows most patients to timely and accurately diagnose this pathology.

The emergence of effective drugs with different and sometimes combined mechanisms of action makes it possible to select adequate therapy and thereby significantly improve the well-being and quality of life of patients with functional disorders of the biliary tract.

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This is primarily due to the difficulties in understanding the term "functional pathology" as such, its debatability, the lack of common clinical and diagnostic criteria, and therapeutic approaches.

Currently, dysfunctions of the biliary tract are understood as violations of the motor-evacuation function of the gallbladder, bile ducts and the tone of the sphincter of Oddi, leading to stagnation of bile.

Often, dysfunction of the biliary tract occurs in children with multiple foci of secondary infection, with helminthic invasion, after viral hepatitis, dysentery, with an incorrect daily routine (a sedentary lifestyle, overwork at school), a disturbed diet (irregular or rare meals at long intervals ), are the result of neurosis, force-feeding, conflict situations at school, family.

Dysfunctions of the biliary tract according to the international classification are divided into two types: dysfunction of the gallbladder and dysfunction of the sphincter of Oddi. There are primary and secondary dysfunctions of the biliary tract.

Primary biliary dysfunctions include diseases based on functional disorders of the biliary system on the basis of disorders of neurohumoral regulatory mechanisms that cause a violation of the outflow of bile and / or pancreatic secretion into the duodenum in the absence of organic obstructions.

Secondary dyskinesias of the biliary tract are combined with organic changes in the gallbladder, sphincter of Oddi, or reflexively occur in various diseases of the abdominal organs.

There are several variants of violation of the motor activity of the gallbladder and the sphincter apparatus of the biliary tract: hypotonic, hypertonic and hyperkinetic. In children with a predominance of the tone of the sympathetic nervous system, hypomotor dysfunctions of the biliary tract are more often observed, with a predominance of parasympathetic hypermotor dysfunctions. However, it should be noted that, given the peculiarity of the physiology of the gallbladder, that is, the impossibility of determining its initial volume due to the constant reabsorption of water from gallbladder bile, this subdivision has more clinical significance. Patients have a pain syndrome that occurs due to stretching of the gallbladder wall, which contributes to excessive release of acetylcholine, which significantly reduces the formation of cholecystokinin in the duodenum. This slows down the contractile function of the gallbladder.

The most accurate method in terms of differentiating various forms of biliary dysfunction is dynamic hepatobiliary scintigraphy, which can diagnose initial functional changes in the biliary tract, reflux into the bile ducts, and determine a non-functioning gallbladder. However, in children, the use of this method is possible only from the age of 12. One of the leading places in the diagnosis of pathology of the biliary tract is occupied by ultrasonography (sonography). It allows you to determine the location and shape of the gallbladder, its external contours, the state of the gallbladder wall, intravesical pathological structures (septa, calculi, polyps, etc.), determine the state of the bile ducts, as well as the liver, pancreas, spleen, identify a disabled gallbladder and its causes. The method can be applied to a child of any age and has practically no contraindications. A prominent place in the diagnosis of pathology of the biliary tract is occupied by cholecystography (oral and intravenous). Currently, due to the invasiveness and difficult tolerability of the method, fractional duodenal sounding is used relatively rarely, which makes it possible to diagnose dyskinetic disorders of the biliary tract organs.

Considering the foregoing, the differentiated therapy of biliary dysfunctions is of great difficulty. It is known that the condition for the normal functioning of liver cells, and thus the entire hepatobiliary system, is the absolute integrity of the membranes and the physiological structure of the cell organelles. Stabilization of cell membranes ensures the physiological secretion of bile, and the restoration of intercellular connections normalizes its outflow. Therefore, the aim of this work was to develop optimal regimens for the treatment of biliary dysfunction using the modern multifunctional drug hepabene.

Materials and methods

Under our supervision there were 130 children from 4 to 14 years old with biliary dysfunction: 30 children from 4 to 7 years old, 50 children from 7 to 10 years old, 50 children over 10 years old.

The diagnosis was based on the results of a clinical examination of patients, laboratory (coprogram, biochemical blood test) and instrumental methods of research (ultrasound examination of the liver, gallbladder, pancreas). Patients had concomitant diseases of the digestive system (gastritis, duodenitis, peptic ulcer, functional disorders of the intestine).

Research results

The hypertensive form of dysfunction was diagnosed in 90 children (69.2%), of which 63 cases (70.0%) were under the age of 10 years. The hypotonic form was found in 40 children (30.8%), of which 23 children (57.5%) were older than 10 years. Inflections of the gallbladder were found in 41 children (31.5%). Signs of inflammation in the gallbladder were diagnosed in 21 cases (16.2%), of which 13 children (61.9%) were older than 10 years.

Clinically, dysfunctions of the biliary tract in children under 7 years of age were accompanied by a decrease in appetite, impaired stool (mainly constipation), episodic nausea. 22 children of this group had pains in the abdomen, mostly paroxysmal in nature, as a rule, after eating. In 20 children of this group (66.7%), ultrasound revealed changes in the pancreas (its enlargement, moderate heterogeneity of the echostructure; the appearance of neutral fat). In 11 children of this group, functional changes in the cardiovascular system were revealed, accompanied by muffled heart tones, soft functional systolic murmur, and a decrease in blood pressure. On the electrocardiogram (ECG) there was an increase in heart rate, a shortening of the PQ interval, a decrease in voltage, in the 5th and 6th chest leads, the T wave was high, pointed, and the P wave was low in the II standard lead.

The obtained data testify in favor of the syndrome of autonomic dysfunction, against which there are manifestations of dysfunction of the biliary tract. At the same time, the predominance of vagotonia is accompanied by a hyperkinetic form of dysfunction of the biliary tract. In the hypotonic form of gallbladder dysfunction, the pains were more often of a dull nature and were prolonged.

In children older than 10 years, on the background of autonomic dysfunction, 13 cases (26.0%) had inflammatory changes in the gallbladder, and in 5 cases, pronounced fibrofocal changes in the pancreas according to ultrasound data, a large amount of neutral fat, iodophilic flora, and soap in the coprogram. That is, in children from 7 to 10 years old, against the background of biliary dysfunction, the risk of developing inflammatory changes in the gallbladder, diagnosed by ultrasound as a thickening of its wall, the appearance of sediment in the cavity, increases.

The conducted studies show that the formation of biliary tract dysfunction in children is closely related to the severity and duration of autonomic dysfunction syndrome and manifests itself in the form of functional disorders at preschool age, progresses in the early school period, and at the age of over 10 years is often registered as a chronic disease. .

Comprehensive treatment in a day hospital included correction of vegetative dysfunction: limiting emotional and physical stress, conducting courses of physiotherapy exercises, physiotherapy, massage of the collar zone, water procedures (contrast shower, soothing baths with essential oils of medicinal herbs). Conducted intermittent courses of choleretic therapy: the alternation of choleretic drugs and decoctions of choleretic herbs. According to indications, intermittent courses of enzyme therapy, myotropic antispasmodics (duspatalin) were carried out.

During the treatment of the hyperkinetic form of biliary dysfunction, sedative and antispasmodic drugs (Duspatalin, Noshpa) were used.

When ultrasound or cholecystography revealed kinks, constrictions of the gallbladder, antispasmodic drugs were prescribed in repeated courses of 10-14 days a month for 34 months. In the future, according to the indications, the course per quarter. Tubage not shown. Exercise therapy is prescribed after the removal of exacerbation phenomena.

In case of hypotonic forms of dysfunctions of the biliary tract, Tubage according to Demyanov was used 23 times a week (for a course of 1012 procedures), combined with the intake of choleretics 2 weeks a month for six months, therapeutic physical education of a tonic type with a gradual increase in load, physiotherapeutic procedures, vitamins.

We studied the effect of the drug hepabene on the function of bile formation and bile secretion in biliary dysfunctions in children. The drug was received by 40 patients from the study group aged 6 to 14 years, suffering from dysfunction of the biliary tract.

Depending on age, hepabene was administered at a dose of 1 caps. x 2 times (children from 6 to 10 years old) up to 1 caps. x 3 times (children over 10 years old) after meals for 10-14 days. When analyzing the obtained data, the following was revealed: the pain syndrome disappeared on the 3-4th day from the start of the drug; normalization of the stool with a tendency to constipation was observed on the 5-6th day from the start of the drug; in 21 children out of 30 (70%) with reduced appetite - improved appetite by the end of the 1st week of treatment; in the coprogram, the disappearance of fatty acids was noted in 16 children out of 24 (66.7%), where their content was noted from moderate to large amounts; neutral fat in feces decreased from moderate and high to negligible in 18 of 26 (69.2%); the size of the liver decreased in all children (34 patients) who had an increase from 1.5 to 3.0 cm below the edge of the costal arch at the time of admission; a decrease in the size of the enlarged gallbladder was observed in 25 children out of 32 (78.1%) who had an increase in it at the time of admission; the presence of sediment in the gallbladder was noted in 12 patients, after 2 weeks from the start of treatment, its disappearance was noted in 3 children (25.0%), which necessitates the continuation of the course of treatment; the level of total bilirubin decreased from 14.8±3.8 µmol/l to 7.5±2.3 µmol/l; the level of direct bilirubin decreased from 3.5±1.2 µmol/l until its complete disappearance; the ALT level decreased from 25±5.0 IU/l to 17.0±2.0 IU/l.

Discussion

The results of the studies show that in children with biliary dysfunction during treatment with the inclusion of the drug hepabene in the therapeutic complex, there is a clinical improvement in the course of the disease, accompanied by a decrease in pain, normalization of stool, improved appetite, and a decrease in liver size. The results of laboratory studies indicated an improvement in the indicators of the coprogram in the form of a decrease in the amount of neutral fat and fatty acids, a decrease in the level of bilirubin and ALT in biochemical blood tests; a decrease in the size of the gallbladder on ultrasound in 78.1% of cases, and in some cases, the disappearance of sediment in the gallbladder (in 25% of cases).

During the treatment, the children tolerated the drug hepabene well, no allergic reactions and side effects were found. However, it is not recommended for patients with Wilson's disease as a hepatoprotective agent due to the accumulation of copper in milk thistle, which is an integral part of the drug.

Thus, the herbal preparation hepabene can be recommended for the treatment of biliary dysfunction in children as a choleretic, antispasmodic and hepatoprotective agent.

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Children's health

Catad_tema Diseases of the liver and biliary tract - articles

Diagnosis of biliary dysfunctions in a polyclinic and their correction

A.A. Ilchenko
Central Research Institute of Gastroenterology, Moscow

Clinical significance of functional disorders of the biliary tract.

From a clinical point of view, biliary dysfunctions (BD) are of particular interest, since untimely diagnosis or their inadequate correction leads to the formation and progression of a number of organic diseases. So, for example, S. Oddi regulates the flow of bile and pancreatic juice into the duodenum, prevents the reflux of intestinal contents into the common bile and pancreatic ducts. This sphincter maintains the pressure in the biliary system to fill the gallbladder. In case of insufficiency with Oddi creates conditions for the formation of an inflammatory process in the biliary tract, which, ultimately, may require the use of surgical treatment.

BDs are one of the mandatory factors involved in the formation of biliary lithogenesis, especially at its initial stages. Therefore, the detection of biliary sludge in the gallbladder is one of the indirect signs of the presence of functional disorders of the biliary tract.

Given the fact that the process of bile formation is continuous (the average daily bile flow rate is 500-1200 ml), and the flow of bile into the duodenum occurs only during meals, the importance of the coordinated actions of the gallbladder, which performs the reservoir function, and the sphincter apparatus becomes obvious. biliary tract, providing timely and in the required amount of bile to the intestines.

Violation of the coordinated work of the gallbladder and the sphincter apparatus of the biliary tract may be accompanied by a change in the normal flow of bile within the biliary tract. Dysfunction of S.Oddi and biliary-pancreatic refluxes underlie the development of biliary pancreatitis, and pancreato-biliary reflux - enzymatic cholecystitis, and according to recent data, gallbladder cancer.

Discoordination in the work of the gallbladder and the sphincter apparatus of the biliary tract (SABT) is one of the reasons for the formation of biliary insufficiency, since the violation of bile outflow due to functional disorders of the biliary tract (FNBT) leads to untimely and insufficient flow of bile into the duodenum.

Considering the physiological significance of bile, the main of which is its participation in lipolysis, insufficient intake of bile leads to disruption of the digestive processes. In addition, bile has powerful bactericidal properties, so exocrine liver failure in combination with c. Oddi dysfunction can contribute to the development of bacterial overgrowth syndrome in the small intestine, which also exacerbates digestion.

In this regard, early diagnosis and adequate therapy of FNBT are an important clinical task for a polyclinic doctor.

Clinic

Functional disorders of the gallbladder and SABT are characterized by spontaneity and a variety of clinical manifestations, the duration of the course, the complexity of diagnosis, which ultimately leads to high appeal of patients for medical care. At the same time, a long and unsuccessful search for a somatic or neurological disease contributes to the formation of hypochondria, depressive disorders, and exacerbates the patient's poor health. Late diagnosis and inadequate therapy can significantly impair the quality of life of such patients, form a stable opinion in patients about the presence of a severe and incurable disease, and force patients to follow a diet for a long time.

A long-term pain syndrome that systematically brings suffering to the patient can cause depressive disorders. Depression that joins pain worsens pain tolerance, intensifies it and is one of the factors contributing to its chronicity. This, on the one hand, causes the wide spread of FNBT, and on the other hand, is the cause of the polymorphism of clinical symptoms, which makes it difficult to carry out differential diagnosis.

BD occurs mainly in women, mostly young, undernourished, asthenic physique, with an emotionally labile psyche.

Clinical symptoms consist of local and general symptoms. The general condition of patients, as a rule, does not suffer. However, it should be noted that FNBT often occurs against the background of an altered neurological or mental status. In such patients, so-called somatovegetative disorders, neuroses, and depressions are often detected. Patients complain of headache, irritability, poor sleep, weakness.

Given the fact that in 85-90% of databases are secondary, careful history taking is essential, which often allows you to understand the cause of biliary dysfunction.

Often, functional disorders of the gallbladder and biliary tract are detected against the background of other diseases of the digestive system (chronic gastritis, duodenitis, chronic pancreatitis, irritable bowel syndrome). The relationship between morphological changes in the mucous membrane of the gastroduodenal zone, cytoarchitectonics of I-cells producing cholecystokinin, seeding Helicobacter pylori and the state of motility of the gallbladder in patients with duodenal ulcer.

For the majority of patients who underwent cholecystectomy, dysfunction of c. Oddi in the form of increasing his tone. This contributes to the development of biliary hypertension, an indirect sign of which is the expansion of the common bile duct, sometimes referred to as "blistering" of the common bile duct.

After vagotomy in the first six months, there is marked hypotension of the biliary tract, gallbladder and Oddi. Resection of the stomach with the exclusion of part of the stomach and duodenum from the act of digestion causes secretory and motor-evacuation disorders due to a decrease in the production of hormones, including cholecystokinin, motilin. The resulting functional disorders are permanent and, in the presence of lithogenic bile, contribute to the rapid formation of gallstones.

BD is often one of the manifestations of combined reflux disorders of the upper digestive tract. In such patients, duodenal hypertension is detected, which is the cause of duodeno-biliary reflux and duodeno-gastric reflux. Contamination of the biliary tree, as a rule, is accompanied by vivid clinical manifestations, leukocytosis, and accelerated ESR. Hypomotor dysfunction of the duodenum with the formation of duodenostasis is accompanied by a decrease in the level of gastrointestinal hormones, including cholecystokinin, which aggravates the course of the disease.

Hormonal dysfunctions of the thyroid gland, adrenal glands, and other endocrine glands play a significant role in the development of motor disorders of the gallbladder and SAGS. Patients with diabetes mellitus develop secondary hypotension of the gallbladder, referred to as diabetic neurogenic gallbladder syndrome. The development of gallbladder dysfunction is associated with diabetic neuropathy, as well as the direct effect of hyperglycemia on gallbladder motility. An increase in progesterone levels also affects the sensitivity of the gallbladder and FAT to cholecystokinin. This fact to a certain extent explains the predominance of females among patients with biliary pathology and dysfunctions of the biliary tract, in particular.

Secondary dysfunctions of the biliary tract can also be observed in diencephalic disorders, right-sided nephroptosis, treatment of hormonal disorders using somatostatin, premenstrual and menopausal syndrome, pregnancy, obesity, systemic diseases, calcium metabolism disorders, etc.

Clinical manifestations caused directly by FNBT depend on their nature and predominant localization. However, it should be noted that primary dysfunctions of the biliary tract can occur with unexpressed symptoms, and secondary dysfunctions of the gallbladder or Oddi usually have a clinic of the underlying disease.

Gallbladder dysfunctions

Clinical symptoms of gallbladder dysfunction are determined by the nature of motor disorders and manifest themselves in the form of varying degrees of pain syndrome. Pain, as a rule, is associated with food intake and appears at the height of digestion and is due to a violation of the emptying of the gallbladder. However, in some cases, they can also appear in the interdigestive period due to a violation of its filling.

Gallbladder dysfunction by hyperkinetic type

It occurs more often against the background of stressful situations, chronic psycho-emotional overload, errors in diet (spicy, fatty, fried foods), strong drinks (tea, coffee), as well as in tobacco smokers.

In the hyperkinetic form of gallbladder dysfunction in the right hypochondrium, colic-like pains periodically appear with irradiation to the back, under the right shoulder blade, right shoulder, less often to the epigastric region, the heart, and intensify with deep inspiration. The pains are short-term in nature and usually occur immediately after an error in diet, cold drinks, exercise, stress, sometimes at night. In some cases, the cause of the pain cannot be determined.

Common symptoms include emotional lability, irritability, fatigue, sweating, headaches, sleep disturbance, tachycardia and other neurotic symptoms. Sometimes there is a short-term reddening of the skin of the face, neck. Persistent red dermographism is characteristic. Body temperature does not rise.

With superficial palpation at the height of the attack, there is a slight pain in the right hypochondrium, with deep palpation - severe pain in the projection of the gallbladder. There are no symptoms of peritoneal irritation. The liver is not enlarged. Symptoms of Ortner, Murphy, Mussy are negative.

Pain stops on its own or disappears, as a rule, after a single dose of antispasmodics, sedatives.

Gallbladder dysfunction by hypokinetic type

The causes of primary dysfunction of the gallbladder according to the hypokinetic type are: a decrease in the sensitivity of the smooth muscles of the gallbladder to neurohumoral stimulation, an increase in resistance from the cystic duct as a result of impaired patency or motor discoordination between the gallbladder and c, Lutkens, anatomical features of the structure of the outlet section and the neck of the gallbladder (enlarged Hartman's pouch, elongated and tortuous neck of the gallbladder, pronounced Heister's spiral valve), which impede the flow of bile from it, congenital pathology of the smooth muscle cells of the gallbladder, spasm of Oddi, irregular nutrition and a sedentary lifestyle.

The causes of secondary dysfunction of the gallbladder according to the hypokinetic type are: inflammatory diseases of the gallbladder (acute and chronic cholecystitis), cholecystosis (diffuse adenomyomatosis, xanthogranulomatous cholecystitis, lymphoplasmacytic cholecystitis, neurofibromatosis, etc.), polyposis of the gallbladder, liver diseases (fatty liver, hepatitis , cirrhosis of the liver), stomach and duodenum (chronic gastritis with reduced secretory function, chronic duodenitis, peptic ulcer with localization in the duodenum), pancreas (chronic pancreatitis with endocrine dysfunction), diseases accompanied by impaired cholesterol metabolism (cholesterol cholecystolithiasis, cholesterosis of the gallbladder), bowel disease (celiac disease, Crohn's disease), surgical interventions (vagotomy, resection of the stomach and duodenum, extensive resection of the small intestine), long-term adherence to a strict diet, irregular food intake with prolonged intervals, endocrine diseases (hypothyroidism, diabetes mellitus), high levels of estrogen in the blood (pregnancy, taking contraceptive drugs, the second phase of the menstrual cycle), long-term therapy with myotropic antispasmodics and somatostatin, systemic diseases (systemic lupus erythematosus, scleroderma) and other causes.

With hypokinetic and hypotonic dysfunction of the gallbladder, dull aching pains in the right hypochondrium, a feeling of pressure, fullness, aggravated by tilting the body forward, are noted. Sometimes there is irradiation of pain in the back, under the right shoulder blade. Pain intensifies against the background of food intake and errors in the diet (spicy, fatty, fried, flour foods).

Frequent symptoms are dyspeptic disorders in the form of nausea, bitterness in the mouth, as well as bloating, constipation.

Women are more often ill, with overweight. The general condition usually does not suffer, the body temperature is normal.

Palpation can reveal moderate pain in the projection of the gallbladder (the intersection of the outer edge of the right rectus abdominis muscle with the lower edge of the liver), sometimes the bottom of the enlarged gallbladder is palpated.

The condition improves after taking cholecystokinetic agents, duodenal sounding, "blind" tubes.

Sphincter of Oddi dysfunction

Dysfunction of the sphincter of Oddi (DSO) can be caused only by muscular dyskinesia of the sphincter or combined with its organic changes in the form of stenosing papillitis. DSO is rare in isolation and is usually associated with hypokinetic gallbladder dysfunction. In clinical practice, hypertonicity of s. Oddi is more common. The development, which is usually based on psychogenic influences (emotional overstrain, stress, etc.), realized through an increase in the tone of the vagus nerve, as a result of which the outflow of bile and pancreatic juice is difficult, digestion processes are disturbed.

DSO is a frequent attribute of the so-called postcholecystectomy syndrome (PCS).

DSO can be suspected in the presence of pain in the epigastric region or the right hypochondrium with irradiation under the right shoulder blade or in the left hypochondrium. Sometimes the pains are girdle in nature with irradiation to the back. Pain is usually associated with eating, but can also appear at night, accompanied by nausea, vomiting. Suspicion becomes more reasonable if other reasons explaining the existing clinical symptoms are excluded, primarily the presence of idiopathic recurrent pancreatitis in a patient. The main clinical manifestation of DSO is considered to be recurrent attacks of severe or moderate pain lasting more than 20 minutes, recurring for at least 3 months. Depending on the differences in the clinical picture, 3 types of DSO are distinguished: biliary, pancreatic and mixed. Clinical manifestations of dysfunction are partly due to pancreatic-choledochal-cystic or choledocho-pancreatic refluxes developing with hypertonicity of Oddi.

For biliary type characterized by pain in the epigastrium or right hypochondrium with irradiation to the back or right shoulder blade. It occurs more often than the pancreatic type. Depending on whether DSO is characterized only by pain or they are combined with other changes confirmed by laboratory or instrumental methods of research, three options are distinguished in the biliary type of dysfunction:

Option 1 - an attack of pain in combination with the following symptoms:

the rise of AST and / or alkaline phosphatase two or more times with a 2-fold study;
delayed excretion of the contrast agent during ERCP (more than 45 minutes);
expansion of the common bile duct more than 12 mm.
an increase in the activity of serum amylase and / or lipase 1.5-2 times higher than normal;
expansion of the pancreatic duct according to ERCP in the head of the pancreas over 6 mm, in the body - over 5 mm;
the time of removal of contrast from the ductal system of the pancreas in the supine position exceeds 9 minutes compared to the norm;

Option 2 - an attack of pain in combination with one or two of the above symptoms.

Option 3 - only an attack of pain in the "pancreatic" type.

At mixed type pains are localized mainly in the epigastrium or are girdle in nature and can be combined with other signs characteristic of various variants of both biliary and pancreatic types of DSO.

DSO, developed or aggravated in connection with cholecystectomy, may be accompanied by other clinical symptoms due to biliary insufficiency (insufficient and chaotic flow of bile into the duodenum), a decrease in the bactericidal content of the duodenal contents and, in connection with this, an increase in microbial contamination of the duodenum.

Laboratory and instrumental diagnostics

The polymorphism of the clinical symptoms of FNBT is so pronounced, especially in individuals with a predominance of neurotic symptoms, that the diagnosis of this disease on the basis of complaints, anamnesis, and objective examination data is often a rather difficult task. In most cases, the diagnosis is established on the basis of the exclusion of other diseases of the gallbladder and biliary tract with the involvement of various laboratory and instrumental research methods.

Diagnostic tests for FNBT can be divided into two groups: screening and clarifying.

screening methods.

Functional liver tests (determination of the level of ALT, AST, GGTP, alkaline phosphatase), pancreatic enzymes in the blood and urine;
Transabdominal ultrasonography of the abdominal organs;
Esophagogastroduodenoscopy with targeted examination of the papilla of Vater.

clarifying methods.

Ultrasound with an assessment of the functional state of the gallbladder and sphincter of Oddi;
Endoscopic ultrasonography;
ERCP with intracholedocheal manometry;
Dynamic cholescintigraphy;
Staged chromatic duodenal sounding.
Drug tests with cholecystokinin or morphine.

If necessary, other methods of laboratory and instrumental diagnostics are used.

In a polyclinic, as a rule, the use of screening research methods is sufficient. The staged chromatic duodenal sounding (ECHD) helps in the diagnosis, which provides sufficient information about the motility of the biliary tract and which can be carried out in outpatient conditions.

In patients with primary dysfunction of the gallbladder, a clinical blood test, liver function tests, the content of pancreatic enzymes in the blood and urine, and endoscopy data, as a rule, do not have significant deviations from the norm. With DSO, during or after an attack, a transient increase in the level of transaminases and pancreatic enzymes is noted. In functional disorders of the gallbladder and SABT, which are the result of pathological changes in the liver, the level and nature of the violation of liver function tests depends on the underlying disease.

Among the instrumental research methods, the leading place in the diagnosis of BD belongs to the ultrasound research method. Transabdominal ultrasonography(TUS) allows you to study the location and shape of the gallbladder, the thickness and structure of its walls, the nature of the intraluminal contents. With FNBT, the gallbladder is usually well visualized, its contours are clear, the wall thickness does not exceed 2.5-3 mm, and the contents are echo-homogeneous.

To clarify the nature of functional disorders of the gallbladder with the help of ultrasound, its volume is examined on an empty stomach and after a choleretic breakfast. The motor-evacuation function of the gallbladder is considered normal if its volume has decreased by 30-40 minutes by? and more from the original, and the emptying ratio is 50-70%.

The assessment of the contractile function of the gallbladder cannot be carried out in isolation from the assessment of the functional state of Oddi, since the hypertonicity of the latter can create a significant obstacle to emptying the bladder, which affects the results of the study.

Indirect signs of hypertonicity with Oddi are an increase in the duration of the latent period (more than 10 minutes after taking a choleretic breakfast) and an increase in the diameter of the common bile duct by more than 1 mm, as well as the cessation of emptying the gallbladder after 10-15 minutes in combination with an increase in the lumen of the common bile duct.

The wide availability of TUS, the absence of radiation exposure, contraindications, and sufficiently high reproducibility of results give this method undeniable advantages in outpatient practice. The undoubted advantage of the method is the possibility of an objective assessment of the effectiveness of FNBT therapy.

Thus, the diagnosis of primary FNBT should be based on the exclusion of organic pathology, and secondary dysfunctions on the identification of the causes that explain it. It should be noted that for the diagnosis of both primary and secondary BD, it is often not enough to use only one method. In this regard, to clarify the diagnosis, the most informative methods for this pathology should be used, and, if necessary, an additional examination should be carried out according to the diagnostic concept.

The diagnosis of primary dysfunction of the gallbladder and / or DSO is established on the basis of a thorough examination and exclusion of other diseases of a functional or organic origin, which may be accompanied by functional disorders of the biliary tract.

The diagnosis of primary dysfunction of the biliary tract is legitimate if the following main criteria for this pathology are identified:

The clinical picture is dominated by neurotic symptoms.
Pain is more often provoked not by food load, but by psycho-emotional overload, stress.
Pain is short-term and may disappear after taking sedatives.
On palpation in the right hypochondrium, there is slight pain, there is no protective muscle tension, negative symptoms of Ortner, Mussy, Murphy.
Pain is not accompanied by a rise in body temperature, changes in clinical blood and urine tests, there are no signs of dyscholia in the biochemical analysis of bile, and microscopy of duodenal bile sediment does not reveal signs of inflammation.
According to TUS, there are no changes in the wall of the gallbladder, its thickness on an empty stomach does not exceed 3 mm, the contents of the gallbladder are echo-homogeneous or with the presence of biliary sludge. In the study of the contractile function of the gallbladder, violations of the motility of the gallbladder are detected (the parameters characterizing the ejection fraction and the emptying coefficient are outside the normal range).
According to the TUS and other clarifying research methods, there are no signs of an organic obstruction that disrupts bile flow. According to ECHD, deviations from normal indicators are revealed (especially in the second and fourth stages of the study).
Clinical examination revealed no other functional or organic pathology that could explain the presence of biliary tract dysfunction.

The accuracy of diagnosing the nature of functional disorders is of fundamental importance, as it determines the choice of treatment tactics, the amount of conservative therapy or surgical intervention, as well as the prognosis of the disease.

Treatment

The main goal of therapy for FNBT is to restore the outflow of bile and pancreatic juice into the duodenum.

Diet therapy occupies an important place in the treatment of patients with FNBT, since proper nutrition, taking into account the nature of motor disorders, contributes to faster rehabilitation of patients and improves the quality of life. A diet with frequent meals of small amounts of food (5-6 meals a day) is recommended, which contributes to the regular emptying of the gallbladder, normalizes pressure in the ductal system of the biliary tract and duodenum.

Alcoholic drinks, carbonated water, smoked, fatty and fried foods, as well as seasonings are excluded from the diet, due to the fact that they can cause spasm with Oddi. In the diet, it is necessary to take into account the influence of individual nutrients on the motor function of the gallbladder and biliary tract. So, with a hyperkinetic type of dysfunction, products that stimulate contractions of the gallbladder should be sharply limited - animal fats, vegetable oils, rich meat, fish, mushroom broths. The use of products containing magnesium is shown, which reduces the tone of smooth muscles (buckwheat, millet, wheat bran, cabbage). The use of egg yolks, muffins, creams, nuts, strong coffee and tea is excluded or limited.

Of the myotropic antispasmodics, drotaverine (no-shpa, no-shpa forte) is widely used in polyclinic practice, however, this drug, like other myotropic antispasmodics - benziklan (halidor), otilonium citrate (meteospasmil), trimebutine (debridate) do not have a selective effect on SABT.

In this regard, mebeverine (Duspatalin) deserves attention, which is included in the Federal Guidelines for the Use of Drugs (formular system) 2009 as the drug of choice in the treatment of IBS. However, domestic studies (Minushkin O.N., Saveliev V.S., Ilchenko A.A.) have shown that this drug also has a selective effect on SABT and restores impaired bile flow. According to M.A. Butov et al. after therapy with Duspatalin, all patients with Oddi dysfunction showed a decrease in the time of latent emptying of the gallbladder, the index of liver secretory pressure, and the index of residual cholestatic pressure.

The course of treatment with mebeverine for biliary dysfunction is usually 2-4 weeks with a daily dose of 200 mg 2 times a day. With hyperkinetic dysfunction of the gallbladder and s.Oddi, as well as with normokinetic dysfunction of the gallbladder and hyperkinetic dysfunction of s.Oddi, the use of mebeverine 200 mg 2 times a day for 4 weeks is indicated. The effectiveness of this therapy reaches 70-100%.

Recent studies have shown that in patients with biliary dysfunction and biliary sludge, the combination of mebeverine 200 mg 2 times a day with ursodeoxycholic acid 10 mg/kg for two months due to the elimination of dysfunction of s.Oddi and the restoration of the contractile function of the gallbladder leads to a decrease in the number patients with discoordination of the sphincters of Lutkens, Mirizzi and Oddi from 50% to 5%, relief of pain and symptoms of biliary dyspepsia in all patients and elimination of biliary sludge in 95% of cases.

Hymecromon (Odeston) is used in the treatment of patients with BD, which has a selective antispasmodic effect on Oddi. Hymecromon is prescribed half an hour before meals, 200-400 mg (table 1-2) 3 times a day. The course of treatment is 1-3 weeks. It should be noted that the drug has a choleretic effect, therefore, with prolonged use, diarrhea may develop. For this reason, it should be used with caution in patients with PCES.

As cholecystokinetic agents, a solution of magnesium sulfate 10-25%, 1-2 tablespoons 3 times a day or a solution of sorbitol 10%, 50-100 ml 2-3 times a day, 30 minutes before meals or 1 hour after meals, is used. With hypokinetic dysfunction of the gallbladder in combination with hyperkinetic DSO - Motilak 10 mg 3 times a day for 4 weeks.

A positive effect is exerted by agents that reduce duodenal hypertension and normalize the processes of digestion in the small intestine. In the presence of microbial contamination, the appointment of doxycycline 0.1 g 2 times, tetracycline 0.25 g 4 times, furozolidone 0.1 g 3 times, nifuroxazide (ersefuril) 0.2 g 4 times, intetrix 1 caps. 4 times within 1-2 weeks. After antibiotic therapy, a two-week course of probiotics (bifiform, etc.) and prebiotics (Duphalak or Hilak-forte) is necessary.

Physiotherapeutic procedures effectively complement drug therapy. Thermal procedures (paraffin, ozocerite), UHF, UHF-therapy, ultrasound on the projection area of the liver and right hypochondrium, as well as the appointment of various baths are shown. Various methods of reflexology are used (needle and laser therapy). For patients with increased irritability and emotional instability, laser puncture is more acceptable, due to the painlessness of the procedures.

The effectiveness of the use of botulinum toxin, which is a powerful inhibitor of acetylcholine release, in DSO is discussed.

The main criteria for evaluating the effectiveness of therapeutic measures for functional disorders of the biliary tract:

Relief of clinical symptoms;
Restoration of the motor function of the gallbladder;
Restoration of the tone of the sphincter apparatus of the biliary tract;
Restoration of pressure in the duodenum.

Thus, the use of modern methods for diagnosing biliary tract dysfunction, taking into account the clinical features of the course of the disease, currently makes it possible to timely and accurately diagnose this pathology in most patients. The modern range of drugs makes it possible to select adequate therapy, which can significantly improve the well-being and quality of life of patients with functional disorders of the biliary tract.

Literature

Ilchenko A.A. Diseases of the gallbladder and biliary tract. "Anacharsis", 2006, 450 p.
Butov M.A., Shelukhina S.V., Ardatova V.B. On the issue of pharmacotherapy of biliary tract dysfunction. Abstracts of the 5th Congress of the Scientific Society of Gastroenterologists of Russia, February 3-6, 2005, Moscow, pp. 330-332.
Delyukina O.V. Motor dysfunctions of the biliary tract and features of the biochemical composition of bile in biliary sludge, methods for their correction. Candidate of medical sciences diss. Moscow, 2007, 132 p.

A complex of clinical symptoms that develop as a result of motor-tonic dysfunction of the gallbladder (GB), bile ducts and sphincters with a simultaneous functional response of the liver, leading either to the correction of biliary disorders, or to their aggravation and consolidation, resulting in chronic biliary insufficiency, leading to a violation digestion - can be considered as biliary-hepatic dysfunction.

This or a similar concept should replace the concept of "biliary dysfunction", since it is quite difficult to isolate and imagine the separate functioning of the biliary tract and liver. This concept was once isolated from hepatic pathology in order to attract attention, accelerate the study and determine the leading therapeutic approaches to "biliary pathology". The present time is characterized by a reverse process aimed at returning the pathology of the biliary tract to the hepatic pathology, and this process is seen quite clearly.

The second, no less important aspect of this problem is the close anatomical and functional relationship of the digestive organs, which determines the wide spread of functional biliary-hepatic disorders in various diseases of the gastrointestinal tract. This forms a variety of clinical manifestations, often makes it difficult to diagnose the entire symptom complex and creates difficulties in treatment, forcing the choice of a drug that affects the entire symptom complex or an adequate pharmacological combination.

Physiology and pathophysiology of the biliary tract

The initial link of the biliary system is the intercellular bile canaliculi formed by the biliary poles of two or more adjacent hepatocytes. The bile ducts do not have their own wall, it is the cytoplasmic membranes of hepatocytes. Intercellular bile ducts, merging with each other at the periphery of the hepatic lobule, form larger perilobular bile ducts (cholangiols, terminal ductules, Hernig's tubules), which have a basement membrane.

Passing through the terminal plate of hepatocytes, in the periportal zone, cholangiols flow into the interlobular bile ducts (ducts, cholangs). The interlobular ducts are lined with cuboidal epithelium lying on a basement membrane. The ducts anastomose with each other, increase in size and become large septal ducts lined with high prismatic epitheliocytes. Starting from this level, there is also a layer of smooth muscle fibers in the ducts. This is the level of the ducts from which innervation and other regulatory influences begin, which can be understood when talking about the regulatory nature of the motility of the biliary tree. The interlobular ducts, merging with each other, form large hepatic ducts (lobar), which leave the liver and form the common hepatic duct, which continues into the common bile duct (CBD). Its beginning is the junction of the hepatic duct with the cystic duct. The CBD is divided into supraduodenal, retroduodenal, retropancreatic, intrapancreatic, and intramural divisions.

The distal part of the common bile duct passes through the thickness of the head of the pancreas and the duct opens on the posterior wall of the descending duodenum 2-10 cm below the pylorus. According to different authors, the width of the ducts varies within certain limits: common bile (OJ) - from 2 to 4 mm; hepatic - from 0.4 to 1.6 mm; cystic - from 1.5 to 3.2 mm. According to x-ray data, the width of the CBD is from 2 to 9 mm; according to ultrasound - with the presence of the gallbladder (GB) from 2 to 6mm, without the gallbladder - from 4 to 10mm. The capacity of the gallbladder ranges from 30 to 70 ml. At the site of transition of the gallbladder into the cystic duct, the muscle fibers take a circular direction, forming the sphincter of the duct of the gallbladder (Lütkens). Motor innervation is carried out by the sympathetic and parasympathetic nervous systems. Nerve plexuses are present in all layers of the biliary system. Sensitive fibers of the gallbladder are able to perceive only stretching. The secretion of bile is continuous throughout the day with some fluctuations. From 0.5 to 2.0 liters of bile is synthesized per day. The direction of bile flow is determined by the interaction of hepatic secretion, the rhythmic activity of the sphincters of the terminal common bile duct, the sphincter of the gallbladder, the valve of the cystic duct, as well as the absorption function of the mucous membrane of the gallbladder and all ducts, which creates pressure gradients that promote bile. From the hepatic ducts and the common bile duct, bile enters the gallbladder at the time of the closure of the sphincter of Oddi (it plays a key role in creating a pressure gradient). Outside of digestion, the sphincter of Oddi is closed intermittently and small portions of bile all the time enter the duodenum. After the end of the digestive phase, bile enters the gallbladder for three or more hours. Most researchers believe that the extrahepatic bile ducts are never at rest, and their active peristalsis is considered from the point of view of the regulation of bile flow. The tone of the duodenum and intraluminal pressure also actively affect the output (flow) of bile. The motor response of the gallbladder and the sphincter of Oddi is largely dependent on the quantity and quality of food, as well as on emotional influences.

The muscles of the sphincter of Oddi do not depend on the muscles of the duodenum. The sphincter of Oddi consists of:

the sphincter itself B.D.S. (Westphal sphincter), which provides separation of the ducts from the duodenum
proper sphincter of the common bile duct;
sphincter of the pancreatic duct.

The work of all departments of the biliary system is strictly coordinated. This coordination is provided by nervous and humoral regulation. The regulatory influences of endogenous opioid peptides are still not entirely clear. In all likelihood, they carry out the same function as the autonomic nervous system, because the normal functioning of any system is ensured by duplicating regulatory factors. The basic principle of the entire regulatory system is multi-level self-regulation (including locally produced hormones and biologically active substances).

The regulatory component is very complex under physiological conditions and is not completely clear in various pathologies of this system.

The gallbladder performs 3 different functions:

accumulation and concentration of bile in the digestive period;
absorption of water and electrolytes;
a contraction by which bile is delivered in portions to the duodenum during digestion.

The gallbladder acts as a bile pressure regulator throughout the biliary system. Possessing a powerful reception, it reflexively regulates the process of bile formation by the liver. So, with an increase in pressure in the biliary tract above 300 mm of water column, the formation of bile decreases sharply, and when the gallbladder is emptied, the process of bile formation increases. In the absence of the gallbladder (cholecystectomy, disabled "non-functioning gallbladder") and increased pressure in the hepatic ducts, the process of bile formation slows down.

The gallbladder and the sphincter of Oddi - their relationship is based on "mutually conjugated" (reciprocal) innervation:

the sphincter of Oddi is contracted → the muscles of the gallbladder are relaxed and it fills with bile;
the sphincter of Oddi is relaxed → the gallbladder contracts and bile flows into the intestine;
there is also synergy in the work of the sphincters of Oddi and Lutkens;
in the absence of the gallbladder, the tendency to dysfunction of the sphincter of Oddi remains permanent. Regulatory influence in this situation is exerted by pressure in the common bile duct and in the duodenum, tk. it is the final link that forms the pressure gradient.

Thus, the main mechanisms for regulating the movement of bile are self-regulation (local and general), the interconnected work of the gallbladder and the sphincter of Oddi, the pressure gradient at all levels of the biliary tree and pressure in the duodenum - which ensure normal bile formation, secretion, concentration of bile and its movement through the biliary ways.

Enterohepatic circulation of bile

The transit of bile salts through the liver depends on their entry from the small intestine. Enterohepatic circulation is carried out by two types of active transit (in the liver and terminal ileum) and two mechanical pumps (gall bladder and small intestine). The limiters of this system are: the deposition of bile in the gallbladder, where most of the bile acids are deposited between meals, and transit through the small intestine. Thus, the presence of the gallbladder is also an important factor in the regulation of enterohepatic circulation of bile, as well as the normal functioning of the small intestine, not only in terms of digestion and absorption, but also in terms of its motor activity.

Classification of functional disorders of the biliary system, clinical variants of dysfunction, diagnostic approaches

According to the latest International Classification, instead of the term "functional diseases of the biliary tract" (Rome Consensus II, 1999), the term "dysfunctional disorders of the biliary tract" is adopted. Regardless of the etiology, they are usually divided into two types:

gallbladder dysfunction;
sphincter of Oddi dysfunction.

In the latest International Classification of Diseases (ICD-10), under heading K82.8, only "dyskinesia of the gallbladder and cystic duct" and under heading K83.4 - "spasm of the sphincter of Oddi" are singled out.

The regulation of the motor activity of the biliary system involves the parasympathetic and sympathetic divisions of the autonomic nervous system, the endocrine system and endogenous opioid peptides, which provide a synchronized sequence of contraction and relaxation of the gallbladder and sphincter apparatus.

It has been shown that moderate irritation of the vagus nerve causes coordinated activity of the gallbladder and sphincters, and strong irritation causes spastic contraction with a delay in bile evacuation. Irritation of the sympathetic nerve helps to relax the gallbladder. Of the gastrointestinal hormones, cholecystokinin - pancreazimin (CCK-PZ) has the maximum effect, which, along with the contraction of the gallbladder, helps to relax the sphincter of Oddi. The stimulator of the production of CCK-PZ is fatty food, and the activator of nervous regulatory influences is the pressure gradient and its changes.

One of the main causes of disorders of the rhythmic activity of the biliary system is not pathological processes in it, but inflammatory processes in the liver, leading to a violation of bile synthesis, a noticeable decrease (change) in pressure in the ductal system and gallbladder, and this leads to a constant spastic contraction of the sphincter of Oddi .

Various surgical interventions (cholecystectomy, vagotomy, resection of the stomach) also lead to significant dysfunction of the biliary system. The formation of bile is a continuous process, but the flow of bile into the intestines occurs only during digestion. This is ensured by the reserve function of the gallbladder and its rhythmic contractions with consequent relaxation of the sphincters of Lutkens and Oddi.

There are primary and secondary dysfunctional disorders. Primary may be associated with a primary decrease in the muscle mass of the gallbladder and the sphincter of Oddi and with a decrease in the sensitivity of the receptor apparatus to neurohumoral stimulation. Such violations are rare and average 10-15%. The bulk of this group of disorders are patients with impaired receptor sensitivity. A small number of receptors can be genetically determined and acquired as a result of inflammatory, degenerative and metabolic disorders.

Secondary dysfunctional disorders of the biliary tract can be observed:

with hormonal disorders (pregnancy, premenstrual syndrome, diabetes mellitus, pathology of the thyroid and parathyroid glands, as well as those stimulated by hormonal therapy - in particular when using somatostatin, etc.);
with liver pathology (acute and chronic hepatitis, cirrhosis of the liver);
with resection of the intestine and stomach (thin, faster with distal resection and thick - more often with left-sided colectomy; with distal resection of the stomach - because the production of cholecystokinin decreases);
with systemic diseases;
cholecystectomy;
drug forms (drugs that affect muscle contractility and change intraluminal pressure);
diseases of the stomach and pancreas.

It should be noted that the presence of these diseases does not imply a stable failure of the regulatory systems and the perceiving apparatus, but a different degree of BS disorders in different phases and periods of the disease course. This determines the "wavelike" disorders, up to periods of fairly long stability, but with a "light" withdrawal of this system from the achieved equilibrium. At the same time, psycho-emotional overload, stressful situations, and general neuroses are of great importance. For the absolute majority of patients who underwent cholecystectomy, insufficiency of the sphincter of Oddi is characteristic, with a continuous flow of bile, its spasm is less often noted. The second most common cause of biliary disorders is distal resection of the stomach, leading to a weakening of hormonal regulation and hypotension of the gallbladder (at the same time, we found - Khokhlova S.Yu., 1996, that hypotension of the gallbladder develops in 67% of operated patients with subsequent formation of stones in gallbladder in the next 5 years in 40% of patients).

The classification of dysfunctional disorders of the biliary tract is presented in table No. 1.

Table number 1.

Classification of dysfunctional disorders of the biliary tract.

1. By localization:

A. Gallbladder dysfunction

B. Dysfunction of the sphincter of Oddi

2. By etiology:

A. Primary

B. Secondary

3. By functional state:

A. Hyperfunction

B. Hypofunction

For ease of perception and based on practical purposes, unidirectional disorders are presented in the classification, although in practice they are more often complex, but with a predominance of one of the components.

The clinical manifestations of these disorders are well known. With hyperkinetic disorders, colicky pains of varying intensity occur, without irradiation or with irradiation to the right, to the back, sometimes to the left half of the abdomen (with the involvement of the ductal system of the pancreas). With hypokinesia, there are dull pains in the right hypochondrium, a feeling of pressure, bursting, which increase with a change in body position and with an increase in intra-abdominal pressure, which changes the pressure gradient for bile flow. Common manifestations for various forms of dysfunction are: bitterness in the mouth, bloating, "unstable stool".

Thus, the central symptom of gallbladder dysfunction is the “biliary” type of pain, and the only objective characteristic (which ultrasound can register) is delayed emptying of the gallbladder or its increased size. The available diagnostic methods do not explain the cause of this dysfunction (there may be several of them, and among them a significant place is occupied by a decrease in the sensitivity of the perceiving apparatus of the gallbladder). Diagnostic criteria for gallbladder dysfunction are episodes of severe or persistent pain localized in the epigastrium or right upper quadrant of the abdomen, characterized by:

episodes lasting 30 minutes or more;
development at least once in the previous 12 months;
permanent nature, which reduces the daily activity of patients and requires a doctor's consultation;
the presence of dysfunction of the emptying of the gallbladder.
lack of evidence of organic pathology.

A very important objective symptom of impaired motility of the gallbladder is the ultrasonic phenomenon of "sludge" (precipitation), which, according to our data, can be presented in two versions: a) diffuse; b) parietal. The parietal variant, depending on the clinical situation, can be characterized as "inflammatory" or without inflammation, but then the elements of the sediment that form it are quite large. In addition, the entire clinical symptom complex should be analyzed - nausea, vomiting, irradiation, provoking factors (food, its nature, emotions).

As for the dysfunction of the sphincter of Oddi, there are 4 types of it (3 types of biliary dysfunction and 1 type - pancreatic dysfunction). Diagnostic criteria are - an attack of pain of the "biliary" type and 3 laboratory and instrumental signs:

rise in the level of AST and / or alkaline phosphatase two or more times with a 2-fold determination;
slowing down the excretion of contrast agents during endoscopic retrograde cholangiopancreatography (more than 45 minutes);
expansion of the common bile duct more than 12 mm.

These symptoms are fixed during an attack.

Ι type of dysfunction is characterized by pain, accompanied by all three laboratory and instrumental signs;

ΙΙ type of dysfunction is characterized by pain and 1-2 laboratory-instrumental signs;

ΙΙΙ type - characterized only by an attack of pain. Patients in this group have only typical pain, without any objective disorders.

ΙΥ type (pancreatic) - it is characterized by "pancreatic" pain and an increase in the level of amylase or lipase. However, with mild pain, hyperenzymemia may be absent.

In cases where endoscopic retrograde pancreatocholangiography makes it possible to exclude the absence of stricture pathology, monometry of the biliary and pancreatic sphincters is shown. . These conditions are generally defined as sphincter of Oddi (SSO) hypertension, which can have serious consequences for the functioning of the pancreato-biliary system (so 60% of patients with partial biliary obstruction have elevated basal CO pressure in the common bile duct).

The World Congress of Gastroenterologists (Bangkok 2002) determined that evidence-based medicine does not require consensus, but evidence. It was also stated there that the sphincter of Oddi dysfunction should not be attributed to clearly defined diseases, but to states with a variable “dysfunction-symptom” relationship. In addition, it has been emphasized that impaired gallbladder emptying is well known as a consequence of inflammatory injury, mechanical obstruction, or autonomic denervation. In the absence of these conditions, it is not entirely clear whether delayed gallbladder emptying can be considered as a separate clinical problem (nosological form). So, in general, the issue of biliary dysfunction is far from the final solution of the whole problem.

Thus, all diagnostic tests for diseases of the biliary tract can be divided into two groups:

screening,
specifying.

Screening methods:

liver function tests, determination of pancreatic enzymes in blood and urine;
ultrasound examination (ultrasound);
esophagogastroduodenoscopy with a mandatory examination of the OBD and the peripapillary zone.

Refinement methods:

Ultrasound with an assessment of the functional state of the gallbladder and sphincter of Oddi; We use ultrasound for patients after cholecystectomy. The essence of the technique is as follows:
- we search and determine the diameter of the CBD on an empty stomach;
- then a food load is carried out: 20 g of butter, cheese, sweet tea - 6.5 g of sugar, white bread .;
- Ultrasound examination 30 minutes after exercise, search and determination of CBD.

Interpretation of results.

Expansion of the CBD after exercise indicates either spasm of the sphincter of Oddi or organic stenosis.
The reduction in the diameter of the CBD indicates the normal functioning of the SO.
The absence of fluctuations in the diameter of the CBD after a food load may indicate either SO hypotension or SO gaping due to the adhesive process.

Monitoring the state of the CBD diameter can be continued for an hour, and the results either increase (organic) or become dynamic (the functional nature of the clinical situation).

Endoscopic ultrasonography;
Endoscopic retrograde cholangiopancreatography (ERCP) with intracholedocheal manometry;
dynamic cholecystography;
drug tests with cholecystokinin or morphine Many aspects (including diagnostic and differential diagnostics of functional and organic pathologies) require further study. However, those studies that are presented above are a sufficient basis for making a diagnosis of biliary system dysfunction and allow you to form an adequate treatment approach.

Principles of treatment of dysfunctional biliary disorders

The main goal of treating patients with dysfunctional disorders of the biliary tract is to restore the tone and normal functioning of the sphincter system, to restore the normal flow of bile and pancreatic secretion through the biliary and pancreatic ducts.

In this regard, the objectives of the treatment of these disorders are:

Recovery, and if it is impossible to replenish bile production in chronic biliary insufficiency, which is understood as a decrease in the amount of bile and bile acids entering the intestine 1 hour after the introduction of the stimulus. After cholecystectomy, dysfunction of the sphincter of Oddi almost certainly develops, since the gallbladder is excluded from the system of normal functioning of the biliary system. In this regard, the loss of bile acids develops with the development of chronic biliary insufficiency (CBN). It also develops in violation of the enterohepatic circulation of bile acids (due to inflammatory processes in the small intestine, due to distal resection of the small intestine, due to resection of the large intestine - mainly left sections). CBN supports not only digestive disorders, but also dysfunctional disorders. The essence of this disorder is as follows, in addition to free bile acids, bile contains conjugates of bile acids, which are surface-active substances (surfactants) that reduce surface tension at the liquid-fat interface. It is this property of bile that makes it possible to create a finely dispersed fat emulsion and prepare fats for the action of pancreatic lipase, i.e. for further hydrolysis of fats. In addition, bile acids not only emulsify fats, but also accelerate the absorption of fatty acids and monoglycerides in the small intestine. As a result of CBI, the hydrolysis of fats and their absorption are disturbed, the loss of fats (steatorrhea) increases, the synthesis of fat-soluble vitamins is disrupted, and in the absence of compensatory, replenishing measures, the process of indigestion is aggravated.
Increased contractile function of the gallbladder (with its insufficiency).
Decreased contractile function of the gallbladder (with its hyperfunction).
Restoration of the tone of the sphincter system.
Restoration of pressure in the duodenum and intestines (on which an adequate pressure gradient in the biliary tract depends).

Treatment Methods

1. Until now, diet therapy plays a significant role in the system of therapeutic measures. Its general principle is a diet with frequent meals of a small amount of food (5-6 meals a day), which contributes to the normalization of pressure in the duodenum, stimulates the hormonal link in the regulation of biliary motility, regulates the emptying of the gallbladder and ductal system. Alcoholic drinks, carbonated water, smoked, fatty and fried foods, seasonings are excluded from the diet, as they can cause a spasm of the sphincter of Oddi. In the diet, the influence of individual nutrients on the normalization of the motor function of the gallbladder, sphincters and biliary tract is taken into account. So, with a hyperkinetic type of dysfunction, products that stimulate the contraction of the gallbladder should be sharply limited - animal fats, vegetable oils, rich meat, fish and mushroom broths. With hypotension of the gallbladder, patients, as a rule, tolerate weak meat and fish broths, cream, sour cream, vegetable oils, and soft-boiled eggs. Vegetable oil is prescribed in a teaspoon 2-3 times a day 30 minutes before meals for 2-3 weeks. For the relief of constipation, dishes that promote bowel movement are recommended (carrots, pumpkin, zucchini, herbs, watermelons, melons, prunes, dried apricots, oranges, honey). This is especially important due to the fact that a normally functioning intestine provides normal intra-abdominal pressure and normal passage of bile into the duodenum. The use of food bran (with a sufficient amount of water) is necessary not only (and not so much) for adequate bowel function, but also to maintain the motility of the biliary tract, especially the gallbladder in the presence of "sludge" in it.

2. Of the drugs that affect the motor function of the gastrointestinal tract, with dysfunctional biliary disorders, use:

anticholinergic drugs;
nitrates;
myotropic antispasmodics;
intestinal hormones (CCK, glucagon);
choleretics;
cholekinetics.

Anticholinergics - by reducing the concentration of intracellular calcium ions, they lead to muscle relaxation. The intensity of relaxation depends on the initial tone of the parasympathetic nervous system, but when using drugs of this group, a wide range of undesirable effects are observed: dry mouth, difficulty urinating, visual impairment, which greatly limits their use. They can be used to stop an attack.

Nitrates (nitroglycerin, nitrosorbide) - cause relaxation of smooth muscles due to the formation of NO free radicals in them, which contribute to an increase in the content of cGMP. Their use, however, is accompanied by the development of pronounced cardiovascular effects and other side effects. In addition, the development of tolerance makes nitrates unsuitable for long-term therapy. Their use can be recommended as the initial stage of stopping an attack, and a course appointment can be justified in case of a combination of coronary artery disease and biliary dysfunction (mutually provoking and supporting the "clinical situation").

Myotropic antispasmodics:

calcium channel blockers (subdivided into non-selective and selective). Non-selective calcium channel blockers are able to relax smooth muscles, incl. and biliary tract, but this effect requires the use of high doses, which practically excludes their use due to pronounced cardiovascular effects. Selective calcium channel blockers (panaverium bromide, ethylonium bromide) act predominantly at the level of the large intestine, where they are mainly metabolized. About 5-10% of the dose of these drugs that enter the bloodstream and are metabolized in the liver can work at the level of the biliary tract - normalizing the gallbladder. However, there is no certainty in their direct effect on the biliary tract. Perhaps their effect is associated with the normalization of the colon, a decrease in intra-abdominal pressure and the restoration of the pressure gradient, which normalizes the flow of bile. Their use is indicated in patients with dyskinetic disorders of the colon (IBS) and simultaneous dysfunction of the biliary tract;
sodium channel blocker - Duspatalin (mebeverine hydrochloride). According to the chemical structure, it is a derivative of methoxybenzamine. Duspatalin blocks the sodium channels of the cell membrane, and therefore the entry of sodium ions into the cell, and therefore calcium, becomes impossible, while the force of muscle contraction is significantly reduced. In addition, the drug blocks the replenishment of the calcium depot from the extracellular space, thereby limiting the release of potassium from the cell and preventing the development of hypotension. The drug is largely metabolized in the intestinal wall and partially in the liver, excreted in the urine, cumulation is not observed. Duspatalin provides an effective antispasmodic effect, quickly relieves the symptoms of hypertensive disorders of the biliary tract - pain in the right hypochondrium, nausea, flatulence. We used the drug in patients with dysfunction of the biliary tract and noted its effectiveness after 2 weeks of treatment in 90% of patients. Efficiency was assessed not only according to clinical data, but also according to changes in the contractility of the gallbladder and the sphincter of Oddi (according to ultrasound data). We believe that the mechanism of action is double: direct - through the effect on muscle tone and indirect - through a decrease in intra-intestinal pressure with "facilitation" of bile discharge when the pressure gradient changes (these data are confirmed by the results of using the drug in the clinic of V.T. Ivashkin - 2003 and the Institute gastroenterology, Ilchenko A.A., 2003).
myotropic antispasmodics with a combined mechanism of action.

In the treatment of hypofunction of the gallbladder, drugs that enhance its motility are used. For this purpose, choleretics can be used, which include preparations containing bile and bile acids (allochol, dehydrocholic acid, liobil, cholenzyme); synthetic preparations (oxamide, hydroxymethylnicotinamide, tsikvalon), some herbal preparations (chophytol, flamin, cholagogum, corn stigmas, etc.), as well as cholekinetics, such as magnesium sulfate, olive oil and other oils, sorbitol, xylitol, holosas, etc. Preparations , stimulating choleresis or containing bile acids, at the same time carry out the function of replenishing chronic biliary insufficiency, restoring impaired digestion of fats.

Drugs with a prokinetic effect (eg, domperidone, trimebutine) may also be used. Selective calcium channel blockers (pinaverium bromide, otilonium bromide) and myotropic antispasmodics (mebeverine) can also be attributed to this group. It should be remembered that the effect of these drugs is largely indirect (either the tone of the sphincter of Oddi decreases, or the pressure in the intestines and duodenum). The effect is always dose-dependent, so the selection of an effective dose is required. Sometimes, in the absence of an effect, drugs that reduce inflammation and visceral hyperalgesia (non-steroidal anti-inflammatory drugs, tricyclic antidepressants in low doses) can be used. Apparently, retains its importance in the treatment of hypokinesia of the gallbladder and cholecystectomy. However, the issue of surgical treatment should be decided very carefully, since the indications for cholecystectomy in this situation are relative, and the final result is always unpredictable.

The choice of drug is very important, if not the main issue. It, in particular, depends on the required speed of obtaining the effect. If the effect should be fast, then it is better to use cholekinetics (the dose of the drug also matters), and if the speed of the onset of the effect is not of paramount importance, then preference should be given to "bile-containing" drugs. In cases where it is also required to provide an anti-inflammatory effect, the choice should be made in favor of synthetic drugs, but the course of treatment should be long. In the presence of concomitant liver pathology, biliary dysfunction and chronic biliary insufficiency, the drug of choice is hofitol, which has a protective effect, choleretic, and thus normalizing motor disorders. Our data confirm its high efficiency and, moreover, it has the effect of lowering cholesterol levels, while not blocking its synthesis, but increasing its metabolism and the synthesis of bile acids; in the presence of stones in the gallbladder, the drug of choice is odeston, as well as in patients after cholecystectomy.

Some approaches to the treatment of biliary dysfunction of the sphincter of Oddi:

when type Ι dysfunction is established, papillosphincterotomy is indicated;
with II-III types - it is possible to use drug therapy;
it should be remembered that hormones (CCK, glucagon) can only temporarily reduce the tone of the sphincter of Oddi; nitrates also provide a very short effect;
botulinum toxin is a strong inhibitor of acetylcholine release. When using this drug in the form of injections into the sphincter of Oddi, its tonicity decreases, bile flow and the clinical condition of the patient improve, but the response to treatment is transient;
with type IV dysfunction, the standard therapy is operative sphincteroplasty and pancreatic lithoplasty (medication is carried out only at the stage of absence of complications).

Conclusion

Thus, recently attention has been drawn to functional disorders of the gastrointestinal tract in general and the biliary system in particular. This is due to the fact that it is functional disorders that lead to pain and other clinical manifestations that form a decrease in the quality of life, and also to the fact that active treatment of functional disorders leaves hope for their cure and eliminates or delays the formation of organic pathology. Currently, diagnostic approaches to disorders of the biliary system are being optimized, and the arsenal of drugs used to treat them is expanding. This provides an opportunity to choose the most effective and safe drug or combination of drugs depending on the pathogenetic features of a particular disorder.

Chronic pancreatitis (Algorithm for diagnosis and treatment tactics)