Acute cholecystitis. Classification. Clinic. Diagnostics. Differential diagnosis. Treatment. Differential diagnosis Kidneys are not palpable

1) Acute appendicitis. In acute appendicitis, the pain is not so intense, and, most importantly, it does not radiate to the right shoulder, right shoulder blade, etc. Also, acute appendicitis is characterized by migration of pain from the epigastrium to the right iliac region or throughout the abdomen, with cholecystitis, pain is precisely localized in the right hypochondrium ; vomiting with appendicitis single. Usually, palpation reveals thickening of the gallbladder and local muscle tension of the abdominal wall. Ortner's and Murphy's signs are often positive.

2) Acute pancreatitis. This disease is characterized by girdle pain, sharp pain in the epigastrium. Mayo-Robson's sign is positive. Characteristically, the patient's condition is grave, he takes a forced position. Of decisive importance in the diagnosis is the level of diastase in the urine and blood serum, the evidence is more than 512 units. (in urine).

With stones in the pancreatic duct, pain is usually localized in the left hypochondrium.

3) Acute intestinal obstruction. In acute intestinal obstruction, pain is cramping, non-localized. There is no rise in temperature. Increased peristalsis, sound phenomena (“splashing noise”), radiological signs of obstruction (Kloiber bowls, arcades, pinnate symptom) are absent in acute cholecystitis.

4) Acute obstruction of the arteries of the mesentery. With this pathology, severe pains of a constant nature occur, but usually with distinct amplifications, they are less diffuse than with cholecystitis (more diffuse). Be sure to have a history of pathology from the cardiovascular system. The abdomen is well accessible for palpation, without severe symptoms of peritoneal irritation. Radioscopy and angiography are decisive.

5) Perforated ulcer of the stomach and duodenum. Men are more likely to suffer from this, while women are more likely to suffer from cholecystitis. With cholecystitis, intolerance to fatty foods is characteristic, nausea and malaise are frequent, which does not happen with a perforated ulcer of the stomach and duodenum; pains are localized in the right hypochondrium and radiate to the right shoulder blade, etc., with an ulcer, the pain radiates mainly to the back. Erythrocyte sedimentation is accelerated (with an ulcer - vice versa). The presence of an ulcerative anamnesis and tarry stools clarify the picture. X-ray in the abdominal cavity we find free gas.

6) Renal colic. Pay attention to the urological history. The kidney area is carefully examined, Pasternatsky's symptom is positive, urine analysis, excretory urography, chromocystography are performed to clarify the diagnosis, since renal colic often provokes biliary colic.

general information

Short description

Approved by the minutes of the meeting
Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan
No. 23 dated 12/12/2013

Chronic calculous cholecystitis is an inflammatory disease that causes damage to the gallbladder wall and motor-tonic disorders of the biliary system, accompanied by the presence of gallstones in the gallbladder cavity. Housing and communal services is one of the manifestations of gallstone disease.

Protocol name- Chronic calculous cholecystitis

Protocol code -

ICD-10 code(s)
K80.1 Gallbladder stones with other cholecystitis

Abbreviations
cholelithiasis
GI gallbladder
CP Chronic pancreatitis
pancreas pancreas
MF Obstructive jaundice
ALT alanine aminotransferase
AST Aspartate aminotransferase
Ultrasound Ultrasound
ESR Erythrocyte sedimentation rate
ERCP Endoscopic retrograde cholangiopancreatography
EFGDS Endoscopic fibrogastroduodenoscopy
ECG Electrocardiogram
CT Computed tomography
MRI Magnetic resonance imaging
LCE Laparoscopic cholecystectomy
HCC Chronic calculous cholecystitis
CE cholecystectomy
CDA Choledochoduodenoanastomosis

Protocol development date- 2013

Protocol Users: general practitioners, surgeons

Classification

Clinical classification
By stages

Clinical classification

With the flow
- asymptomatic (latent)
- symptomatic

Stage by the presence of gallstones
- biliary sludge (prestone)
- stone(s) (stone)*

Number of stones
- single
- multiple

Localization
- gallbladder
- bile ducts**

Complications

Cholecystitis:
- spicy
- chronic

Acute cholecystitis:
- empyema of the gallbladder
- perivesical abscess
- acute perforation of the gallbladder or cystic duct
- fistula of the gallbladder
- dropsy of the gallbladder

Cholangitis:
- spicy
- chronic

Mechanical jaundice
- bile duct strictures and sphincter of Oddi
- Mirizzi syndrome
- perforation of the common bile duct
- fistula of the common bile duct
- cholangiogenic abscesses
- bowel obstruction due to gallstones
- biliary pancreatitis

* The name of the stone stage is not included in the diagnosis, only its characteristics are indicated in terms of the number and location of gallstones.
** If possible, indicate which

Diagnostics

List of basic and additional diagnostic measures

Basic diagnostic measures
- General blood analysis
- General urine analysis
- Capillary blood clotting time
- Coagulogram
- Bilirubin and its fractions
- Definition of AST
- Definition of ALT
- Determination of urea and creatinine
- Determination of total protein and protein fractions
- Determination of blood cholesterol
- Determination of blood sugar
- Microreaction
- HIV
- HbsAg, Anti-HCV
- Coprogram
- Determination of blood amylase
- Determination of alkaline phosphatase
- Determination of blood group and Rh factor
- ECG
- Plain chest x-ray
- Ultrasound of the hepatoduodenal zone and abdominal organs
- EFGDS
- Seeing a therapist

Additional diagnostic measures:
- Duodenal sounding
- CT scan
- Magnetic resonance cholangiography
- Hepatobilioscintigraphy
- ERCP
- Bacteriological, cytological and biochemical examination of duodenal contents

Diagnostic criteria

Complaints and anamnesis:

For biliary dyspepsia:
- loss of appetite;
- a feeling of bitterness and dryness in the mouth;
- nausea in the morning or after eating a certain type of food, sometimes vomiting of bile, which does not bring relief;
- bloating, loose stools with a tendency to constipation.

With moderately severe abdominal pain syndrome
- dull aching pain or a feeling of heaviness or pressure in the right upper quadrant of the abdomen of a constant nature, aggravated by a deep breath, in a position on the left side, decreasing in a forced position - on the right side with legs tucked to the stomach.

An attack of biliary colic
- an attack occurs suddenly, against the background of complete well-being, usually in the evening or at night. It is characterized by sharp spasmodic pain, which patients describe as cutting, tearing, or stabbing. The intensity of pain within a few minutes increases to the maximum. The patient tosses about in bed, cannot find a position that would relieve suffering, groans, screams with a grimace of pain on his face. Perhaps the development of pain shock. Sometimes during an attack, painful sensations fluctuate in intensity.
- increased sweating, tachycardia, nausea, mild vomiting of bile that does not bring relief, bloating
- pain in the right hypochondrium, most often in the projection of the gallbladder or epigastric region, with typical irradiation along the right half of the body - back and up - under the scapula, in the collarbone and supraclavicular region, shoulder, neck and jaw. Less often, the pain radiates to the left - behind the sternum, to the region of the heart, simulating (or provoking) an angina attack (S.P. Botkin's angina, or cholecystocardial syndrome)
The duration of an attack of biliary colic varies from 15 minutes to 5 hours. At the end of the attack, the patient has an unpleasant sensation in the liver for some time. Pain recurs at various intervals.
Some time after the pain associated with biliary colic subsides, signs of obstructive jaundice may appear. With uncomplicated cholelithiasis, jaundice is short-lived. Patients note a slight yellowness of the sclera and skin, a short darkening of the urine and discoloration of the feces.

Physical examination:
- severe pain on palpation in the epigastrium and right hypochondrium, radiating upward, to the right shoulder, neck and back under the right shoulder blade,
- bloating,
- pain on palpation at the point of the gallbladder.
- moderate tachycardia (up to 100 beats per minute).
- icteric coloration of the skin and sclera
- a typical picture of obstructive jaundice: urine becomes dark, frothy, feces discolored, persistent skin itching appears, depriving the patient of sleep, scratching on the skin.
- when a stone is infringed in the Vater nipple, the pain is localized in the epigastrium with irradiation to the back and both hypochondria.
- during an attack or immediately after it, the urine becomes dark (the release of bile pigments into the blood and urine)
- fever (up to 39-40 ° C) with tremendous chills and sweating
- limited muscle tension in the right hypochondrium and sharp pain on palpation of this area.
- positive phrenicus symptom (Mussi-Georgievsky symptom), Ortner and Murphy symptoms
- the bottom of the tense, sharply painful gallbladder is palpated
- with the progression of the inflammatory process, the phenomena of local peritonitis are noted
- sometimes in the right hypochondrium a painful infiltrate is palpated without local symptoms of peritoneal irritation
- a symptom of Shchetkin-Blumberg with perforation of the gallbladder or with a breakthrough of a formed perivesical abscess.

Laboratory research
- In the general analysis of blood in acute cholecystitis or cholangitis, neutrophilic leukocytosis is detected with a shift of the leukocyte formula to the left, acceleration of ESR.
- In the general analysis of urine with MF, bile pigments are detected.
- With MF, there is an increase in the level of total bilirubin due to its direct fraction
- With symptoms of liver failure, an increase in the level of aminotransferases (AlT and AST), an increase in the activity of alkaline phosphatase, hypercholesterolemia, hypoproteinemia and dysproteinemia. The coagulogram may show an increase in prothrombin and thrombin time
- When involved in the process of pancreas - an increase in amylase and blood glucose levels.

Instrumental Research
Ultrasound is the main method for diagnosing cholelithiasis.
Oral cholecystography makes it possible to judge the functional state of the gallbladder, the radiolucency of stones and the degree of their calcification. This information is extremely important for the selection of patients for litholytic therapy and extracorporeal lithotripsy (ECLT).
Intravenous cholegraphy makes it possible to obtain a clear image not only of the gallbladder, but also of the extrahepatic bile ducts.
ERCP helps to clarify the condition of the bile ducts.
Hepatobilioscintigraphy makes it possible to suspect the presence of stones or strictures in them, to assess the functional state of the gallbladder and liver cells.
Indications for expert advice:
Consultation with an oncologist for suspected cancer of the bile ducts or head of the pancreas.

Differential Diagnosis

Acalculous cholecystitis	With uncomplicated cholelithiasis, biliary colic is not preceded by dyspeptic phenomena; biliary colic disappears suddenly, after which patients immediately experience not only significant relief, but usually feel healthy. The liver and gallbladder are painless on palpation, usually there is no "temperature tail", there are no "elements of inflammation" in the duodenal contents. Of great importance is the method of contrast cholecystography, ultrasound.
Biliary dyskinesia	With biliary dyskinesia, there is a clearer connection between the onset of pain syndrome and negative emotions, the absence of tension in the abdominal wall during biliary colic; the diagnosis is confirmed by the negative results of duodenal sounding and mainly by the data of contrast cholecystography, which does not reveal stones.
Right-sided renal colic	Irradiation of pain is characteristic: upward - with biliary colic; down, in the leg, in the groin, in the genitals - with kidney. The presence of dysuric phenomena in renal colic, hematuria or erythrocyturia after a painful attack is important.
Peptic ulcer of the duodenum	In addition to the anamnesis, the results of deep palpation also testify to peptic ulcer disease, in which a dense, sharply painful cord is often determined - a spasmodic pyloroduodenal area. The diagnosis is confirmed radiographically and endoscopically.
Pancreatitis	Localization of pain to the left in the epigastric region and to the left of the navel with irradiation to the back, to the left side of the spine, left shoulder blade, left half of the shoulder girdle is characteristic of pancreatic diseases and is usually not observed in cholelithiasis. The increased content of amylase in the blood or diastase in the urine is also important.
Acute appendicitis	With the subhepatic location of the appendix - diagnostic laparoscopy
Cancer of the biliary tract and pancreas	The rapid development of jaundice, its connection with the previous pain syndrome, the presence of biliary colic in history indicate gallstone disease, while the relatively slow and gradual development of jaundice gives reason to suspect a malignant tumor. X-ray (with contrast cholegraphy) single or multiple stones are found. Less often, the shadows of stones are also visible on the survey radiograph. It will help in the diagnosis of ultrasound, CT, blood test for tumor markers

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Treatment

Treatment goals:surgical removal of the gallbladder, removal (or dissolution) of stones from the bile ducts, creation of conditions for unhindered outflow of bile

Treatment tactics:

Non-drug treatment

It is used for uncomplicated gallstone disease.
1) Compliance with sleep and rest, the exclusion of negative emotions.
2) Diet number 5

Medical treatment

Oral litholytic therapy.
1) Henofalk 750-1000 mg (3-4 capsules) once at bedtime.
2) Ursofalk 750-1000 mg (3-4 capsules) once at bedtime.
These drugs do not act on pigment stones, such treatment is carried out only in patients with non-calcified stones.

Lithotripsy
Selection criteria for patients with cholecystolithiasis (with symptomatic and asymptomatic forms of the disease) for lithotripsy:
1) single and few (2-4) calculi, occupying less than 1/2 of the volume of the gallbladder;
2) preserved contractile-evacuation function of the gallbladder.
Contraindications for lithotripsy:
1) multiple cholecystolithiasis, occupying more than 1/2 of the volume of the gallbladder;
2) calcined stones;
3) decrease in the contractile-evacuation function of the gallbladder
4) "disabled" gallbladder;
5) bile duct stones and biliary obstruction;
6) impossibility of carrying out enteral litholysis after crushing of calculi (gastroduodenal ulcer, allergy);
7) pregnancy.
Lithotripsy is usually combined with litholytic therapy.
Patients with an acute attack of gallstone disease (hepatic colic) are prescribed antispasmodic and analgesic drugs until the pain disappears.
3) Papaverine (antispasmodic) 10-20 mg; in / m, s / c or / in; the interval between injections is at least 4 hours.
4) No-shpa (antispasmodic) 40-80 mg IV slowly, the maximum daily dose is 120 mg
5) Platifillin (antispasmodic) 1-2 ml of a 0.2% s / c solution. the maximum daily dose is 0.03 g.
6) Atropine (antispasmodic) 0.25-1 mg 1-2 times a day i/m, s/c or i/v; the maximum daily dose is 3 mg.
7) Baralgin (analgesic + antispasmodic) is administered intramuscularly or intravenously (very slowly!) 5 ml each (if necessary, injections are repeated after 6-8 hours). Daily dose 10 ml.
8) Analgin 1-2 ml of a 50% or 25% solution i/m or i/v 2-3 times a day; no more than 2 g per day.

To enhance the therapeutic effect, antispasmodics can be combined with analgesics. In the absence of effect in a hospital, they resort to novocaine blockade.

In the presence of inflammatory processes in the biliary tract, antibiotic therapy is used. In this case, drugs should be used that are able to act against etiologically significant microorganisms and penetrate well into the bile.

Drugs of choice:
1) Ceftriaxone (cephalosporin) IM or IV 1-2 g/day (maximum up to 4 g per day) + metronidazole (5-nitroimidazole derivative) 1.5-2 g/day.
2) Cefoperazone (cephalosporin) IM or IV 2-4 g/day (maximum up to 8 g per day) + metronidazole (5-nitroimidazole derivative) 1.5-2 g/day.
3) Ampicillin/sulbactam (combined penicillin) IM or IV 6 g/day, maximum daily dose 12 g/day.
4) Amoxicillin / clavulanate (combined penicillin) in / m or / in 3.6-4.8 g / day; the maximum daily dose is 6 g.
Alternate mode:
1) Gentamicin or tobramycin 3 mg/kg per day + ampicillia 4 g/day + metronidazole 1.5-2 g/day
2) Netilmicin 4-6 mg/kg per day + metronidazole 1.5-2 g/day
3) Cefepime 4 g/day + metronidazole 1.5-2 g/day
4) Fluoroquinolones (ciprofloxacin 400-800 mg intravenously) + Metronidazole 1.5-2 g/day

Enzyme preparations
With concomitant chronic pancreatitis, enzyme preparations are prescribed (Festal, Creon, Panzinorm, Mezim).
1) Creon inside, during or after a meal. The average dose for adults is 150 thousand units / day; with complete insufficiency of the exocrine function of the pancreas - 400 thousand units / day. With prolonged use, iron preparations are prescribed simultaneously.
2) panzinorm inside 1 tablet during meals 3 times a day.
3) festal inside, 1 dragee (an enteric-coated tablet) 3 times a day during or immediately after meals.
4) mezim inside, during or after a meal. The average dose for adults is 150 thousand units / day; with complete insufficiency of the exocrine function of the pancreas - 400 thousand units / day.

Hepatotropic therapy
1) Gepadif inside adults are prescribed 2 capsules 2-3 times a day, regardless of food intake, children aged 7-14 years - 1-2 capsules 2-3 times a day. The course of treatment is at least 2 months. Depending on the severity of the disease, the course of treatment is repeated 2-3 times a year. Parenterally, the drug is administered intravenously. The daily dose for an adult is 1 vial. Before administration, the contents of the vial should be dissolved in 400-500 ml of a 5% dextrose (glucose) solution. In case of glucose intolerance, the contents of the vial can be diluted in 20 ml of water for injection, administered intravenously slowly, by stream.
2) Heptral inside, in / m, in / in. In intensive care - in the first 2-3 weeks of treatment, 400-800 mg / day is prescribed intravenously (very slowly) or intramuscularly; the powder is dissolved only in the special attached solvent (L-lysine solution). For maintenance therapy - inside 800-1600 mg / day between meals.

Other types of treatment - no

Surgical intervention

Types of surgical interventions:
1) Laparoscopic cholecystectomy
2) Cholecystectomy from minilaparotomic access
3) Traditional cholecystectomy
4) Traditional cholecystectomy with intraoperative drainage of the choledoch according to Pikovsky (with indurative pancreatitis); in the presence of cholangitis - according to Vishnevsky or Ker.
5) EPST as a separate type of operation or in combination with cholecystectomy and choledochotomy.
6) Dressings.

In acute calculous cholecystitis, after preparing the patient, cholecystectomy is performed in an emergency and delayed manner: in the first 2-3 days from the onset of the disease by the laparoscopic method, with technical difficulties - by the open method. Operation on an emergency basis is indicated for symptoms of peritonitis, with a tense enlarged gallbladder, and the presence of a pericystic infiltrate. In chronic calculous cholecystitis, the operation begins with laparoscopy. If the hepatoduodenal zone is intact, the operation is continued laparoscopically.

Indications for cholecystectomy using laparoscopic technique:
- Chronic calculous cholecystitis;
- Polyps and cholesterosis of the gallbladder;
- Acute calculous cholecystitis (in the first 2-3 days from the onset of the disease);
- Chronic acalculous cholecystitis;
- Asymptomatic cholecystolithiasis (large and small stones).

If the common bile duct is enlarged and contains calculi, laparotomy, classical cholecystectomy and choledochotomy with calculus extraction, in some cases CDA, are performed. Indications for the imposition of CDA: choledocholithiasis or the presence of putty-like masses and sand in the bile ducts; cicatricial narrowing of the distal part of the common bile duct over several centimeters, combined with stenosis of the Vater papilla; expansion of the hepatic and extrahepatic bile ducts with thickening of their walls; obturation of the terminal part of the common bile duct due to chronic indurative pancreatitis. Contraindications to CDA application: duodenostasis; cicatricial and ulcerative deformity of the duodenum; undilated, thin-walled or sclerotically altered common bile duct; obturation of the common bile duct above the intended location of the anastomosis.
In the postoperative period, antibacterial, infusion, hepatotropic and symptomatic therapy is carried out.

Prevention

To prevent postoperative complications, it is necessary to provide:
- a full examination of patients, the identification of concomitant pathology and its correction in the preoperative period.
- hepatotropic therapy in the pre- and postoperative period
- Adequate antibiotic therapy during and after surgery
- timely hospitalization of patients with complicated cholelithiasis
- timely surgical intervention in complicated cholelithiasis
- thorough sanitation of the abdominal cavity
- decompression of the biliary tract in breast cancer should be early and carried out according to urgent indications

Prevention of GSD. Primary - impact on risk factors for the development of cholelithiasis:
- gradual decrease in body weight;
- do not use fibrates and progestogens;
- avoid estrogen therapy;
- avoid long periods of fasting;
- limit in the diet foods rich in cholesterol (offal, egg yolks, caviar, etc.), increase the amount of dietary fiber;

Prevention of recurrent cholelithiasis (secondary prevention):
- continue treatment after the dissolution of the stones for another 3 months.
- impact on risk factors for the development of cholelithiasis

Information

Sources and literature

Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013

Information

List of protocol developers
Rakhmatullin Yusupzhan Yakubovich Candidate of Medical Sciences, Associate Professor of the Department of General Surgery of KazNMU named after. S.D. Asfendiyarova

Conflict of interests
The developer of the protocol has no financial or other interest that could affect the issuance of an opinion, and also has no relation to the sale, production or distribution of drugs, equipment, etc., specified in the protocol.

Reviewers:
Ospanov O.B. - Doctor of Medical Sciences, President of the Kazakhstan Association of Endoscopic Surgeons.

Conditions for revision of the protocol: after 5 years from the date of publication

Attached files

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Recognition of acute cholecystitis in a typical clinical course and timely hospitalization is not very difficult. Diagnosis becomes difficult in atypical course, when there is no correspondence between pathomorphological changes and their clinical manifestations, as well as in complicated forms. Diagnostic errors occur in 10-15% of cases. The most common misdiagnosis is acute appendicitis, acute pancreatitis, perforation of gastroduodenal ulcers, acute intestinal obstruction, right-sided pyelonephritis or paranephritis, right-sided lower lobe pneumonia.

- Differential diagnosis of acute cholecystitis with acute appendicitis.

Differential diagnosis of acute cholecystitis with acute appendicitis is often a difficult task. This happens when the gallbladder is low, when it goes down to the right iliac region and its inflammation simulates acute appendicitis. And, conversely, with a high subhepatic location of the appendix, its inflammation clinically differs little from acute cholecystitis. In order to distinguish between these two diseases, the details of the anamnesis should be taken into account. Patients with acute cholecystitis often note that there were pains in the right hypochondrium before, as a rule, they arose after eating fatty and spicy foods.

Pain in acute cholecystitis is more intense with characteristic irradiation to the right shoulder, shoulder blade and supraclavicular region. Symptoms of intoxication and the general manifestation of inflammation in acute cholecystitis are more pronounced than in acute appendicitis. When palpation of the abdomen, it is possible to more clearly identify the localization of pain and tension of the abdominal wall, characteristic of each of the diseases. Of great importance is the detected enlarged gallbladder. In acute cholecystitis, appendicular symptoms are not determined. The performed ultrasound examination allows to detect signs of acute cholecystitis and its complications. In the most difficult diagnostic situations, diagnostic laparoscopy allows all doubts to be resolved.

- Differential diagnosis of acute cholecystitis with acute pancreatitis

There is much in common in the clinical picture of acute cholecystitis and acute pancreatitis, especially since a combination of these diseases is possible. In both diseases, the onset is associated with errors in the diet, there are epigastric pains, repeated vomiting. Distinctive features of acute pancreatitis is the girdle nature of pain. On palpation, the greatest pain is in the epigastric region, in the right hypochondrium it is less pronounced than in acute cholecystitis, an increase in the gallbladder is not detected. Acute pancreatitis is characterized by an increase in the content of pancreatic enzymes in the blood plasma, primarily amylase, as well as diastasuria. Of great importance in the differential diagnosis are ultrasound and diagnostic laparoscopy. The latter is crucial in difficult diagnostic situations. In addition, it allows, when confirming a particular diagnosis, to solve the problem of treatment by performing an adequate operation.

Due to the fact that in acute cholecystitis, disorders of the gastrointestinal tract are sometimes very pronounced - repeated vomiting, bloating, intestinal paresis with gas and stool retention - it is necessary to carry out a differential diagnosis with acute intestinal obstruction. It helps in the differential diagnosis that in acute intestinal obstruction, pain is more often cramping in nature. Such clinical symptoms as "splashing noise", resonant peristalsis, Val's positive symptom and other specific signs of acute intestinal obstruction also contribute to the correct diagnosis. Of decisive importance is the survey radiography of the abdominal cavity, which reveals Kloiber's cups.

- Differential diagnosis of acute cholecystitis with gastric and duodenal ulcers

With an atypical course of a perforated ulcer of the stomach and duodenum, when the perforated hole is covered, the clinical picture may resemble that of acute cholecystitis. In these cases, anamnestic data characteristic of both diseases should be taken into account. For a perforated ulcer, vomiting is not characteristic, common signs of inflammation at the onset of the disease. Significant assistance in the diagnosis is provided by x-ray examination, which reveals free gas in the abdominal cavity during perforation.

- Differential diagnosis of acute cholecystitis with inflammatory diseases of the kidneys

The clinical picture of acute cholecystitis can be simulated by right-sided renal colic or inflammatory diseases of the kidneys (pyelonephritis, paranephritis). Pain in the lumbar region, characteristic of these diseases, may radiate to the right hypochondrium. Pain can be determined on palpation of the abdomen in the right hypochondrium and to the right of the navel. For acute diseases of the right kidney, pain is characteristic when tapping on the lumbar region on the right, a positive symptom of Pasternatsky. When examining a patient, attention should be paid to anamnestic data on the presence of urological diseases, urinalysis, which allows to detect hematuria or changes characteristic of inflammation (protein, leukocyturia). In some cases, it is useful to perform excretory urography, ultrasound scanning, chromocystoscopy.

- Differential diagnosis of acute cholecystitis with acute viral hepatitis.

Acute viral hepatitis may be accompanied by pain in the right hypochondrium. In contrast to acute cholecystitis, this disease can reveal a prodromal period, important epidemiological data (contact with patients with hepatitis, blood transfusion, administration of biological products). When examining a patient with hepatitis, as a rule, an enlarged gallbladder, an infiltrate in the right hypochondrium, and peritoneal phenomena are not detected. Essential for suspected hepatitis is the study of the content of liver enzymes in the blood plasma.

Viral hepatitis is characterized by a steady increase in the level of transaminases. Although these hepatic enzymes can be elevated in acute cholecystitis, after 24-48 hours their concentration returns to normal levels and, with rare exceptions, their values reach the same level as in hepatitis.

- Differential diagnosis of acute cholecystitis with non-viral hepatitis.

An exacerbation of chronic non-viral hepatitis in alcoholics can be clinically difficult to distinguish from acute cholecystitis. At the same time, there are also pronounced pains and soreness on palpation in the right hypochondrium. When studying the anamnesis, it is possible to reveal the fact of alcohol abuse. Local and general signs of inflammation are not very pronounced. Hepatomegaly is often found. Leukocytosis of peripheral blood and plasma transaminases are usually normal or slightly elevated. Important signs of degenerative and inflammatory changes in the liver are detected by ultrasound. An especially accurate diagnosis can be made with an ultrasound-guided liver biopsy. In difficult diagnostic cases, diagnostic laparoscopy should be resorted to.

Differential diagnosis of acute cholecystitis with acute right-sided pneumonia and pleurisy.

Acute right-sided pneumonia and pleurisy are characterized by cough, chest pain associated with respiratory movements. In the differential diagnosis, auscultation and percussion of the chest help. At the same time, weakening of breathing, wheezing, dullness of percussion tone, characteristic of pneumonia and pleurisy, are revealed. Chest x-ray will reveal infiltration of the lung tissue, the presence of fluid in the pleural cavity.

- Differential diagnosis of acute cholecystitis with acute myocardial infarction.

Differential diagnosis with acute myocardial infarction is based on clinical and electrocardiographic data. Unlike acute cholecystitis, pain in acute myocardial infarction is localized behind the sternum and in the left half of the chest, accompanied by hemodynamic disturbances. At the same time, general and local signs of inflammation are not characteristic. Of decisive importance are changes in the ECG in dynamics.

Surgical diseases Tatyana Dmitrievna Selezneva

38. Differential diagnosis and treatment of acute cholecystitis

Differential diagnosis. Acute cholecystitis must be differentiated from perforated gastric and duodenal ulcers, acute pancreatitis, acute appendicitis, acute coronary insufficiency, myocardial infarction, acute intestinal obstruction, pneumonia, pleurisy, thrombosis of mesenteric vessels, nephrolithiasis with localization of the calculus in the right kidney or right ureter, and also with liver diseases (hepatitis, cirrhosis) and biliary dyskinesia. Biliary dyskinesia must be differentiated from acute cholecystitis, which is of practical importance for the surgeon in the treatment of this disease. Dyskinesia of the biliary tract is a violation of their physiological functions, leading to stagnation of bile in them, and later to the disease. Dyskinesia in the biliary tract mainly consists of disorders of the gallbladder and the closing apparatus of the lower end of the common bile duct.

Dyskinesia includes:

1) atonic and hypotonic gallbladders;

2) hypertonic gall bladders;

3) hypertension and spasm of the sphincter of Oddi;

4) atony and insufficiency of the sphincter of Oddi. The use of cholangiography before surgery makes it possible to recognize the main varieties of these disorders in patients.

Duodenal sounding makes it possible to establish the diagnosis of an atonic gallbladder if there is an abnormally abundant outflow of intensely colored bile that occurs immediately or only after the second or third administration of magnesium sulfate.

With cholecystography in the position of the patient on the stomach, the cholecystogram shows a picture of a flabby elongated bladder, expanded and giving a more intense shadow at the bottom, where all the bile is collected.

Treatment. When the diagnosis of "acute cholecystitis" is established, the patient should be urgently hospitalized in a surgical hospital. All operations for acute cholecystitis are divided into emergency, urgent and delayed. Emergency operations are carried out according to vital indications in connection with a clear diagnosis of perforation, gangrene or phlegmon of the gallbladder, urgent operations - with the failure of vigorous conservative treatment during the first 24-48 hours from the onset of the disease.

Operations are performed in a period of 5 to 14 days and later with a subsiding attack of acute cholecystitis and an observed improvement in the patient's condition, i.e., in the phase of reducing the severity of the inflammatory process.

The main operation in the surgical treatment of acute cholecystitis is cholecystectomy, which, according to indications, is supplemented by external or internal drainage of the biliary tract. There is no reason to expand the indications for cholecystostomy.

Indications for choledochotomy - obstructive jaundice, cholangitis, impaired patency in the distal sections of the common bile duct, stones in the ducts.

author

From the book Surgical Diseases author Tatyana Dmitrievna Selezneva

From the book Urology author O. V. Osipova

From the book Faculty Pediatrics author N. V. Pavlova

From the book Hospital Therapy author O. S. Mostovaya

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From the book Internal Diseases author Alla Konstantinovna Myshkina

From the book Surgical Diseases author Tatyana Dmitrievna Selezneva

author N. V. Gavrilova

From the book Infectious Diseases: Lecture Notes author N. V. Gavrilova

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From the book Dog Treatment: A Veterinarian's Handbook author Nika Germanovna Arkadieva-Berlin