Choledocholithiasis - causes, symptoms, diagnosis and treatment
Choledocholithiasis - The presence of stones in the bile ducts, causing a violation zhelcheottoka. Symptoms choledocholithiasis determined by the degree of overlap duct stone and include pain, jaundice and sometimes fever. In the initial stages of the disease may pass without symptoms. For an accurate diagnosis is performed ultrasound of the liver and gall bladder, holedohoskopiyu, endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, MR cholangiopancreatography, evaluate biochemical liver tests. Remove the stones surgically or endoscopically.
Choledocholithiasis
gallstone disease, in which stones are formed in the common bile duct or get there from the gallbladder. Stones in the gallbladder - a very common phenomenon. They occur in approximately one-third of women and a quarter of men in Europe and North America. Among patients with cholelithiasis about 5-15% suffer choledocholithiasis. After removal of the gall bladder increases the risk of choledocholithiasis, but it occurs in such cases generally asymptomatic. The importance of this problem is also associated with frequent complications that require emergency care and create a risk to the life of the patient. Diagnosis and treatment of choledocholithiasis carried out at the offices of gastroenterology and abdominal surgery.
sclerosing cholangitis, cysts in the bile duct stricture, formed after inflammatory diseases and manipulation, worm infestation (helminth infections).
The pathogenesis of choledocholithiasis is an increase in pressure in the bile ducts. As a result, the stone is moved from one department to another, causing irritation of the walls, edema and further overlap the common bile duct lumen. If the rock is small, and in the common bile duct and the papilla of Vater no strictures, he can independently reach the duodenum. Otherwise, the complete or partial blockage of the bile duct. As a result of the evacuation of bile is disturbed, choledoch above plugging space expands, there is inflammation, formed a favorable environment for bacterial growth.
acute cholecystitis; It can be dull, aching or sharp enough, with small changes of intensity. The pain is localized in the epigastric or right upper quadrant, often gives back. When the stone falls to papilla of Vater, pain can get shingles character as in acute pancreatitis. If this section is not blocked by a stone, it goes into the duodenum, and all symptoms disappear on their own until the next attack.
The second symptom of choledocholithiasis - jaundice. It develops in about 12 hours after the onset of pain, sometimes the process can drag on for hours. This pain decreases or disappears completely. Feature jaundice when choledocholithiasis - its intermittent character. The intensity of yellowing of the skin and mucous membranes is enhanced, it weakens. This makes it possible to differentiate the disease from cancer of the pancreatic head, acute viral hepatitis, leptospirosis, which can also sometimes occur with severe pain. When protracted course of choledocholithiasis with a significant flow obstruction in patients discolored feces, until Ahola, dark urine.
Complicated choledocholithiasis cholangitis, pancreatitis, with prolonged duration - secondary biliary cirrhosis. Upon accession cholangitis (cholangitis), except for the main symptoms, the patient is fever, signs of intoxication (nausea, vomiting, severe general weakness). Sometimes patients complain of intense pain in the back. Pancreatitis is manifested by severe pain on the left side or the pain of herpes character, continuous vomiting, decreased peristalsis or complete intestinal paresis. In the blood, increased levels of pancreatic enzymes. Cirrhosis develops long after frequent recurrence of choledocholithiasis, cholangitis complicating.
Ultrasound of the liver and gallbladder, liver biochemical tests. The blood test is often determined by elevated levels of bilirubin, alkaline phosphatase. ALT, AST, in most cases remain in the normal range. Changes in the biochemical composition of the blood may be small, fast return to normal when the stone is evacuated from the lumen of the common bile duct. In asymptomatic make screening tests of blood biochemistry, in which you can find periodic moderate rises in bilirubin and alkaline phosphatase.
Laboratory data may not always help in making a diagnosis or to determine the degree of obstruction of the ducts. Therefore, to specify the presence of choledocholithiasis advisable to carry out other investigations. Ultrasound of the liver and gallbladder can detect ductal extension, attributes the stagnation of bile, calculi in the lumen of the common bile duct or gallbladder. If the study does not give a complete picture, additional wire ERCP. The advantage of this method is that you can simultaneously carry out surgery to remove a stone from the duct.
One of the methods more accurate diagnosis of choledocholithiasis is percutaneous transhepatic cholangiography. In complex cases a MR holedohopankreatografiyu. Computed tomography (CT) of the biliary tract is rarely used, because it is not sufficiently informative in this case.
ERCP. During endoscopy through the sphincter of Oddi introduced a special balloon catheter, which extends the duct and makes it easy to remove the stone. If a large stone, or spend choledochotomy sphincterotomy. ERCP technique allows to remove a stone in 85% of cases. Stones larger than 18 mm is crushed beforehand. Do this by using a mechanical lithotripter, by laser or magnetic wave lithotripsy. After extraction efficiency crushing concrements in biliary ERCP rises to 90%.
When it is impossible to remove the stone by endoscopic method, resorting to surgery. The operation was performed by a classical method or by laparoscopy. During the operation carried out choledochotomy or complete removal of the gallbladder (cholecystectomy). Remove gall bladder is recommended in all cases of recurrence of choledocholithiasis. Conservative treatment of choledocholithiasis is rare, but in cases where surgery is not possible.
The prognosis for choledocholithiasis
Due to the fact that often gives choledocholithiasis complications prognosis of this disease is quite serious. Without timely treatment is rarely possible to avoid obstruction, obstructive jaundice, cholangitis, in severe cases - pancreatitis and cirrhosis. Postoperative complications (especially after classical open surgery) is about 15%, so now for the treatment of choledocholithiasis often try to apply endoscopic and laparoscopic techniques.
After removal of the stone recurrence for five years, developing in about a quarter of all patients. Repeated attack choledocholithiasis is recommended to remove the gallbladder. For prophylaxis administered ursodeoxycholic acid. Take it should be not less than six months of the year, otherwise the effectiveness of treatment would be questionable.