Clinical recommendations for chronic cholecystitis. Algorithm for conducting patients with gum disease

RCHRH (Republican Center for Development of Health Protection of the Ministry of Health of the Republic of Kazakhstan)
Version: Archiv - Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2010 (Order No. 239)

Chronic cholecystitis (K81.1)

General information

Short description

Chronic cholecystitis- chronically fired up the level of the rump mikhur with step-by-step sclerotherapy and deformation.

protocol"Cholecystitis"

Cody MKX-10:

K 81.1 Chronic cholecystitis

K 83.0 Cholangitis

Till 83.8

Up to 83.9 Fagots of young people, unspecified

Classification

1. For interruption: gostry, chronic, recurrent.

2. Behind the character of burning: catarrhal, phlegmonous, gangrenous.

3. For the phase of incapacitation: aggravated, uncommon remission, remission.

diagnostics

diagnostic criteria

Skargi and anamnesis: dull pain in the right upper quadrant (especially for fatty and greasy food, gostrich stravs, gas drinks) in addition to dyspeptic drinks (hypoxia, blues, bridging, loss of appetite), head b_l, Weakness, stomachache.

Physical details: resistance of muscles in the right side ribs, positive symptoms: Kerr (painfulness in the point of the cheek bone), Ortner (pain in the oblique blow on the right side ribs), Murphy (pain in the right side of the ribs 'ї), soreness with palpation of the right sidebar, symptoms of chronic chronic intoxication.

Laboratory Doslidzhennya: UAC (may be advised SHOE, pomirny leukocytosis).

Instrumental doslіgennya: at ultrasonic inspection - the reduction and growth of the female mink at 2 mm, the increase in the increase in the lower by 5 mm 2 at the upper limit, the appearance of paravigal inequality, sludge-syndrome (1998)

Shown for consulting fahivts:

dentist;

Lykar physiotherapist;

Likar exercise therapy.

Switching of the main diagnostic entries:

2. Zagalny blood analysis (6 parameters).

3. Out-of-the-box analysis of the section.

4. Viznachennya AST.

5. Viznachennya ALT.

6. Viznachennya bilirubinu.

7. Doslidzhennya kalu on Coprology.

8. Duodenal probe.

9. Bacteriological analysis of zhovchi.

11. Dentist.

12. Lykar physiotherapist.

13. Likar exercise therapy.

Change of additional diagnostic entries:

1. Esophagogastroduodenoscopy.

2. cholecystocholangiography.

3. Viznachennya diastasis.

4. The value of blood glucose.

5. Viznachennya puddle phosphatase.

6. Viznachennya cholesterol.

7. cholangiopancreatography (computer, magnetic resonance imaging).

8. Retrograde cholangiopancreatography.

9. Electrocardiography.

Differential diagnosis

Likuvannya beyond the cordon

Take a lykuvannya in Korea, Izrail, Nimechchin, USA

Otrimati the consultation on medturism

lykuvannya

Meta likuvannya:

Correction of motor poles;

Reduction of pain and dyspeptic syndromes.

tactics:

1. Dietotherapy.

2. Protisapalnaya therapy.

3. Metabolic therapy.

4. Correction of motor debris.

5. Zhovchogіnnі therapy.

non-drug treatment

Diet includes frequent receptions up to 4-6 times a day. Dobova caloricity to the ratsion given the calorific value for a healthy child. At the stationary ailments I will take away style No. 5 for Pevzner.

drug therapy

For usunenia information zhovchі vikorystovuyutsya antibacterial drugs wide range children that take part in enteropathic circulation, accumulate in therapeutic concentrations in zhovchny mikhury... Vibor є co-trimaxazole preparations, 240-480 mg 2 times for doba.

Also, ciprofloxacin can be used for 250-500 mg 2 times for doba, ampicilin trihydrate 250-500 mg 2 times for dobu, erithromicin 200-400 mg / day. skin 6 years, furazolidone 10 mg / kg / day. in 3 doses of metronidazole 125-500 mg / day, in 2-3 doses. Appointment of two remaining drugs, especially dozіlno in case of giardiasis.

Antibacterial therapy should be carried out in the middle for 8-10 days. However, due to the urahuvannya of the vision of the microfloria and of the sensitivity, it can be revived or changed.

symptomatic lykarska therapy take a look at the shows:

For normalization of rukhovaya funktsii zhovchividnyh shlakhiv prokinetics are recommended - domperidone at 0.25-1.0 mg / kg 3-4 times a day, for 20-30 minutes. to go, trivial rate of 3 days;

Zhovchogіnnі - silimarin with fumarin 1-2 capsules 3 times a day before the menstruation of fenipentol, or magnesium sulfate, triviality to the course not less than 3 days, chemical choleretics - oxyphenamide (shortage of drugs, shortages) 3 types;

In case of a secretory deficiency of the pidshlunkovaya zalozya, pancreatin is indicated at 10,000 OD per lipase x 3 times per hour, stretching 2 times;

Algeldrate + magnesium hydroxide, (or the other non-absorbable antacid drug) at a single dose in 1.5-2 years after the day.

Before an hour I will attack the cheekbones, it is important that you get the pain syndrome earlier. With a tsієyu metoyu priznachayut - no-shpu 1 t. X 3 p. in d., buscopan 1 t. x 3 r. in the village of Yaksho, if we do not know the attack in the middle of the middle, then internally inject 0.2% of the rasses of platifilin, 1% solution of papaverine.

Ailments require dispensary caution, as well as sanitation of chronic diseases of infection, for which 40% of ailments suffer chronic tonsillitis, Worm infections and lambliasis.

Prophylactic come in:

1. The increase in infectious diseases.

2. Remediation of the formation of gum disease.

further away

It is necessary to see the children after the postponed aggravated cholecystitis in the course of 3 years. The transition to the foreign style is guilty, but we can do it. The course of specific treatment (zhovchoginny therapy) is guilty of taking a whiskey from the stationary for the first time 4 times (in 1,3,6, 12 ms.), And in the offensive 2 rocky 2 times. The course of treatment is trivial 1 m / s. and including the sign of cholekinetics and choleretics.

Transfer of basic medicines:

1. Ampicilinu trihydrate, 250 mg, table; 250 mg, 500 mg capsule, 500 mg, 1000 mg powder for preparation of an injection solution, 125/5 ml in a bottle suspension

2. Erythromicin, 250 mg, 500 mg tablets; 250 mg / 5 ml oral suspension

3. Furazolidone, 0.5 mg tab.

4. Ornidazole, 250 mg, 500 mg tablets.

5. Metronidazole, 250 mg, 0.5 in vials for infusion

6.Intraconazole, oral solution 150 ml - 10 mg / ml

7. Domperidone, 10 mg tab.

8.fumarin, caps.

9. Magnesium sulfate 25% - 20 ml amp.

10. Pancreatin, 4 500 OD caps.

11. Algeldrate + magnesium hydroxide, 15 ml pack.

12. Co-trimaxazole, 240 mg, 480 mg tab.

13. Pirantel, 250 mg tablet; 125 mg oral suspension

14. Mebendazole 100 mg chewable tablet

Transfer of supplementary medicines:

1. Oxafenamid 250 mg, tab.

2. Ciprofloxacin 250 mg, 500 mg, table; 200 mg / 100 ml vial, bottle for infusion

3. Ursodeoxycholic acid 250 mg, caps.

4. Selimarin, caps.

5. Hepabene, caps.

6. Aevit, caps.

7. Pyridoxine hydrochloride 5%, 1.0 amp.

8. Tiaminobromide 5%, 10 amp.

Indicators of efficiency of treatment:

Singing zagostrennya zahvoryuvannya;

Reduction of pain and dyspeptic syndromes.

hospitalization

Shown before hospitalization (plan):

Variations of pain syndrome and dyspepsia;

Part (more than 3 times per ric) relapse.

Necessary communication before the planned hospitalization:

1.UZD organs black wastes.

3. Alt, AST, bilirubin.

4. Coprogram, zishkrib for enterobiasis.

information

Dzherela and Literature

1. Protocols for diagnostics and treatment of ill health of the Ministry of Health of the Republic of Kazakhstan (Order No. 239 dated 07.04.2010)
   1. 1. CLINIC RECOMMENDATIONS based on evidence of medicine: Per. from English / Ed. I. N. Denisova, V. I. Kulakova, R. M. Khaitova. - M.: GEOTAR-MED, 2001. - one thousand two hundred and forty times from.: Il. 2. Clinical recommendations + pharmacological assistant: Ed. I. N. Denisova, Yu. L. Shevchenko - M .: GEOTAR-MED, 2004 .-- 1184 p.: Il. (Series "Evidence-Based Medicine") 3.Society of Nuclear Medicine Procedure Guideline for Hepatobiliary Scintigraphyversion 3.0, approved June 23, 2001 SOCIETY OF NUCLEAR MEDICINE PROCEDURE GUIDELINES MANUAL MARCH 2003. 4. EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES AND TREATMENT CHARACTER S. Bongala, Jr., MD, FPCS, Committee on Surgical Infections, Philippine College of Surgeons, Epifanio de los Santos Avenue, Quezon City, Philippines Shilyaev і іn., M, 2002. 6. Practical gatroenterology for pediatricians, V.N. Preobrazhensky, Almaty, 1999 .. 7. Practical gatsroenterology for pediatricians, M.Yu. Denisov, M. 2004.

information

List of publications:

1. Head of the gastroenterology department of the Aksai RDKB, F.T. Kipshakbaeva.

2. Assistant of the Department of Children's Ailments KazNMU ім. S. D. Asfendiyarova, Ph.D., S.V. Choi.

3. Likar for a review of gastroenterology at the Aksai RDKB V.N. Sologub.

Attached files

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(Housing and communal services) - congestion, when calculus occurs in the gum mikhury (cholecystolithiasis) or in the gallbladder prototypes (choledocholithiasis), which can be manifested by attacks of pain in the right flesh of the protozoan (hepatic congestion of a cholecystitis).

In the developed lands of the zhovchnokam'yan, ailments are often reported to the number of most cases, zhovchny stones appear in 10-20% of the population. Women get sick 2-3 times more often, not among choloviks, and in some 60-70 years of housing and communal services they diagnose in 30-40% of cases.

Growth of grubby ailments with a decline in sickness, malaise, chronic diseases (chronic cholecystitis, cholangitis), dysfunction of the gallbladder and youthful galls, impaired metabolism, irregularity It is more important to reduce the metabolic degradation of bilirubin and cholesterol, to increase the concentration of those in the gum, and for the establishment of gum stones. Violation of cholesterol metabolism and alterations in the blood to promote obesity, reddish diabetics, Atherosclerosis, hyperlipoproteinemia, gout, taking drugs (for example, oral contraceptives). Prior to the admission of the ryvnya bilirubin in the female and the establishment of the pigment stones, to produce the deterioration of the function of the liver in chronically ill, hemolytic anemia, helminthosis and inn.

Great value in the development of gum ailments is inefficiently eating - overwhelmingly eating rich fats, so to avenge cholesterol and refining in carbohydrates, grassy grasses, I think about the reaction of sickness Before the setting of stones in the ruminant, they also produce hunger, great interruption between the pills, or vidmov as a snack, low calorie, with a low fat diet (up to 600 kcal in less than 3 days).

Threatening the development of gum disease ailments wrap around a small amount of normal weight, and moreover, women of the middle age are especially concerned about genetic schism. Chim more masa tila, tim vishche risik housing and communal services. Women with superfluous mass of tila 6 times more often work for housing and communal services, to win 10 kg to fight for development. Hіpodynamіya pіdvischu risik establishment of gum stones. According to the results, it was established that women, who regularly, for 2-3 years per week, vikonuyut physical right, rizik viz.

In most cases of zhovchnokam'yan, the ailment is asymptomatic. When quiet symptoms of ailments appear, lie down as a number of stones in the moth, of the magnitude and growth. The main clinical manifestation of housing and communal services is a rapid attack of pain in the right side of the road (pechinkova kolka), which, as a rule, develops in order to receive fatty or lubricated energy, physical stress, driving robots in the most efficient way. There is a high intensity of wine in the right side, in the right hand, the shoulder blade or half of the shoulder on the right, the area of ​​the heart and can be supressed by nudota, bloating, in the belly, in the stomach, and in dryness. In a number of vipads, there is a period of receiving spasmolytic symptoms.

If any of these symptoms appear, it is necessary to safely turn to the doctor to clarify the diagnosis and to indicate an adequate diagnosis.

Zhovchnokam'yan's ailment can be facilitated by the development of the state of cholecystitis, by the blockage of zhovchivy nobles from the wines of the zhovtyanitsa, by the eruption of the ruminant and development of peritonitis, by the penetration of the intestines of the great gut stones in the nephews.

When the attack is painful for more than 5 hours, at the same time, the temperature of the body has moved up to 38 ° C, and there has also been an increase in the number of eyes, a dark color of the eye, light color is not required turn for medical aid(I will help you with the viclikati).

Parts of the stinging gum ailments can be produced to the firing of gallants - to cholangitis, as well as ignition process pancreatitis, intestinal microflora destruction and constipation.

Remember! Self-help diagnostics and systematic use to allow getting ahead of the progress of ill health and development of those who are not safe for life.

If the diagnosis of the ailment is evident, it is necessary to consult a surgeon for a specific tactic of treatment. Accurately take into account the way of life, children, follow the recommendations on the intake of drugs.

For the prevention of gum disease and the hope of the progress of the disease, such recommendations:

1. Snack 4-5 times a day in small portions. The interval between priyoms is less than 8 years old. Take it at the same hour. Tse spriy to the shortened vidtok zhovchi.
2. Do not eat food, the temperature is lower than 15 ° C and 62 ° C - it may cause spasm of young people and provoke pain attacks.
3. Live herbs, cooked from fresh products of natural origin, in cooked, baked, star-stewed viglyad. Do not pick in greased, salted, pepper, smoked herbs. Tse zapobіzhit zagostrennya zagvoryuvannya.
4. Do not get overwhelmed, do not get nervous, do not allow negative emotions. Collapse more, lead an active way of life.
5. Even if you have oversized fat, you have completely reduced the energy efficiency of up to 2000-2200 kcal, having reduced a portion of all fat to 30% (not more than 1/3 of the fat of foodstuff, 2/3 - of rose oil) and easy to consume. I will increase the number of zukor. Take in the number of grub fibers in the day, especially for the harvest of vegetables and fruits. Enjoy your body, or do not starve.
6. Combine the appropriate cholesterol with a good choice of products, such as bagati (egg meat, meat, liver, fatty meats, ribs, lamb and cow fat, lard). To increase the organism of excess cholesterol, drink products, rich in magnesium salts, as well as Greek and porridge.
7. With the presence of stones in the ruminant, it is seen as a strong stimulant of the quickness of the ruminant - kava, vidvariv zhovchoginnyh herbs and mix in products that will stimulate the speed of the ruminant ( roslinn_ oils heart, rich meat, ribs, mushroom bouillon, fresh bacon, soft-boiled eggs, lemon).
8. It is also possible to fix the establishment and growth of cholesterol stones in the zhovchny mikhury vzhivannya rib fat abo ribi (to take revenge on omega-3 fatty acids, so that cholesterol is under siege).
9. Cinnamon drink vitamins, tea with hipster fruit and goblin berries. Protisapalnu, spasmolytic, lightly weakening and changing the processes of fermentation in the intestines by the effects of volodya tea from the fruits of the minus. You can drink tea 3 times a day or drink tea for a day.
10. If you take medications designated by the other people in the drive fellow sickness, It is necessary to inform the house about your doctor, so that the actions of them can reduce the motility of the cheekbones, reduce the stasis of gum and stone-relief (for example, nitrate, antagonism of calcium contraceptive, antiretroviral therapy) At the end of the day, your doctor will carry out medication correction to optimize the drug effect.
11. Give serious respect to the chronic diseases of infections, igniter get sick organs of worms, worm infections. Viklyuchit from the ratsion of products, as nadayut allergiziruyuschie diyu.
12. Regularly see the doctor (not earlier than once at the test), go through the necessary information. We do not like the correct selection of drugs, effective treatment and increased speed.

It is more correct to take care of the regimen, medical and medicinal recommendations to take the prevention of gum ailments.

Do not get mad about yourself, for the joy of your relatives, or for those you know.

Take care of your health!

Rusticum stone without cholecystitis (K80.2)

gastroenterology

General information

Short description

PROFILNA COMISIA OF SPECIALNOSTIES "GASTROENTEROLOGY" OF THE MINISTRY OF HEALTH PROTECTION AND SCIENCE OF UKRAINE

ROSІYSKA gastroenterological associations

ZHOVCHNOKAM'YANA KHVOROBA

value

Zhovchnokam'yana ailment (housing and communal services, syn. Holelitias) is a chronic illness with genetic schism, in which case it is spared the establishment of stones in the zhovchnyh plots.

When the stones are established in the gummy duct (FM), talk about "cholecystolithiasis", in the western prototypes - about "choledocholithiasis", in the internal hepatic ducts - about "intrahepatic cholelithiasis" 1.

Malunok 1... Localization of gum stones is possible.

Basic code for MKH-10

K80 Zhovchnokam'yan ailment.

History of vivchennya zvoryuvannya

Evidence about the discovery of gum stones in the ancient dzherels. Zhovchni stones vikoristovuvalis in the quality of ritual embellishments and in cult rites. Descriptions of the signs of housing and communal services are to be found in the houses of Hippocrates, Avicenny, Celsus. They were saved from the fact that the founders of medical science long ago, Galen, Vezal, were able to see gum stones at the rosette of corpses.

French likar Jean Fernel (J. Fernel) in the XIV century described a classic picture of a gum disease, and also having put a ring on the gum.
Nimetsky anatomist A. Vater (A. Vater) in the XVIII century described the morphology of gum stones and vkazuvav, the cause of their approval є thickened gum. Chemically advancing gum stones were first crushed by D. Galeati in the middle of the 18th century.
About the gum disease, accumulated at that hour by the German anatomist and physiologist A. Haller in his works "Opuscula pathologica" and "Elementa physiologiae corporis humani" in the middle of the VIII century.
A. Galler divided all the stones into two classes: 1) large egg-like stones, as a rule, one by one, which are stored from the “unsweetened mouth, like when it starts to melt and good fires”, and 2) more, other times They appear not only in the mikhury, but in the first steps. In such a rank, the current classification of gum stones with a base for cholesterol and pigment has actually been primed for a long time.
Galler's partner, F.P. da la Salle, saw a substance from the gum stones, "I go to fat", represented by thin, silky plates. In the end of the XVIII - the ear of the XIX century, there is cholesterol in the pure view of A. de Fourcroy, and in the middle - the famous chemist L. Gmelin and the French chemist M. Chevreul; ostnіy calling it cholesterol (from the Greek. chole - zhovch, stereos - ob'amny).

In the middle of the 19th century, the first theory of the nature of gum stones appeared, in the middle there were two main directions:
1) the first reason for the establishment of stones is the destruction of the stove's camp, because the product is pathologically changing the zhovch,
2) the first reason - pathological changes(Zapalennya, stasis) in zhovchny mіkhury.
The forerunner of the first is directly the English licar G. Thudichum. A clerk of another bouv S.P. Botkin, who ordered the meaning of ignition changes in the development of gum disease and reportedly describing the symptoms of sickness and treatment.
One of the first experimental models of calculous cholecystisis was dissolved by P. S. Ikonnikov in 1915.

In the end of the 19th century surgical treatment gum disease: in 1882, Carl Langenbach (C. Langenbuch) was responsible for the cholecystectomy, and in Russia the operation was performed for the first time in 1889 by Yu. F. Kosinsky.
Great additions to the development of the surgical pathway were made by S.P. Fedorov, І. І. Grekov, A.V. Martinov.
At 1947r. descriptions of "postcholecystectomy syndrome" which can help you to preserve the symptoms or symptoms of pain relief. I mean, I mean, the key heterogeneity of the understanding, and even more so.

In the end of the 20th century, the traditional cholecystectomy replaced the traditional cholecystectomy (M. , older than P. S. and spivavt., 2005). In this hour, the robot-assisted technology of laparoscopic cholecystectomy is actively introduced.
In the end of the XX-th ear of the XXIth the development of an important view in the field of genetic education for housing and communal services. Accumulated evidence of successful consumption of ursodeoxycholic acid in the preparation of gum calculi. In the last few years, the problem of housing and communal services has been screwed up to respect in the connection with the "epidome of the overworldly vagi" and the increase in the minds of the adoption of stones in children and children.

Ethiology and pathogenesis

Ethiology and pathogenesis

The reason for the establishment of stones is to serve overworldly concentration of zhovchi. Razr_znyayut stones of two main types (Figure 2):

1) cholesterol... Cholesterol (CS) in them is> 50% (and> 90% in the so-called "pure cholesterol stones"). Also in their warehouse there are pigments, calcium salts, matrix to be stored with glucoproteins from a slime. For purely cholesterol stones, you may have a larger size, one at a time, zhovtuvato-bili. On the surface of cholesterol stones, a calcium shell can be established.

2) pіgments... Cholesterol in them<20%, они состояь преимущественно из кальция билирубината и полимероподобных комплексов кальция и гликопротеинов слизи. Пигментные камни, в свою очередь, разделяют на 2 подтипа:

a. black(It is stored in excess of calcium bilirubinate, add a lot, it is easy to cry, size<5 мм, рентгенопозитивные в 50-75% случаев). Образование черных камней наиболее характерно для гемолиза и цирроза печени.

b. brown(It is stored from calcium salts of non-conjugated bilirubin, mucin glycoproteins, cholesterol, palmitate and calcium stearate; myaks, sharuvati, X-ray neutral). Osvita brown stones imperiously chronic ignition process in the internal and post-pecuniary zhivchnyh trails. In the core of the stone, there may be an inclusion of bacterial components, which will support a powerful connection with infection.

baby 2 ... Types of gum stones: A) cholesterol, B) black pigments, C) brown pigments.

Stone size up to 1 cm cleverly means yak "dry", 1-2 cm - "middle" and> 2 cm - large, if you carry out the instrumental diagnostics, you can be grated in the assessment of stone size.

Mechanisms of the formation of gum stones with the presence of singular factors in the development of bіlіary sludge and housing and communal services, are presented in table 1.

Table 1... The factories to produce bilary sludge, cholesterol and pigment stones before approval.

Making cholesterol stones

Biliarny sludge is served for the occasional uyavlennyy, the first glimpse of the XC-stones.

Cholesterol (CS) - one of the main components of the gum; in the water phase, the wine is in the advanced stage - in the viglyadi small micelles or bulbs include cholesterol, phospholipid (PL), gum acids (LC). Cholesterol and PL are secreted by hepatocytes in the gum of single-globular bulbs, which are then transformed in the change of mycelia.

In the minds of the obvious excess of cholesterol ("lithogenic zhovch"), unstable, unstable cholesterol bulbs occur, as they become angry in large lamellar structures - precipitates of crystals.

Osvita lithogenic zhovchі is the most important stage of stone-making. Bezposrednі reasons for the adoption of lithogenic zhovchі:

1) advising the approval of the CS:

Due to the increased activity of hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase - an enzyme that is responsible for the synthesis of cholesterol in

pechinki
- as a result of the increased cholesterol accumulation by liver cells from the bloodstream and transferred to the gum (spring, on the basis of high-caloric food, rich in carbohydrates and cholesterol);

2) change of status of HS, FL, LCD:

In addition to the decline in the activity of enzymes, which control the synthesis and transfer of storage cich (table 2, babies 3),

In addition, there is a decrease in the synthesis of fatty acids in the liver and destruction of the intestinal hepatic circulation.

The main factor that is responsible for the fluidity of FA accumulation in the bloodstream and transfer to the gum is the activity of FA transporters on the canalicular membrane.

hepatocyte - a stubble in the back of the gut canal.

Table 2. Changes in the production of cholesterol, PL and fatty acids in the gum with the presence of genetic changes in the activity of enzymes, which control the exchange and transport of cholesterol.

Malunok 3. A cassette of transporters of the components of the gum on the canalicular membrane of the hepatocyte.

Adding genetic factors the frequency of occurrence of gum stones in relatives of the first stage of dispute in the housing and communal services sector, as well as the expansion of housing and communal services among singing nationalities.

Patients from housing and communal services have an increase in cholesterol instead of cholesterol in a diet of cholesterol in a diet of cholesterol. When the housing and communal services are out, the cholesterol secretion does not move on to the smallest cholesterol cholesterol. In such a rank, genetic factors, coupled with high-calorie and high-calorie and high-calorie crops, form the basis for the development of housing and communal services.

The role of genetic factors is confirmed by pre-born twins. In monozygous twins, genetic factors can be estimated at 25%, minds in the midst of the colony - in 13%, individual peculiarities of the style of life - in 62%.

The polymorphism of the gene is described, but the code is ABCG5 / G8 - intrahepatic carrier of cholesterol - in case of a shift of the thymus secretion in the gum (Table 2).

The high risik of housing and communal services among the surrounding nationalities is associated with the peculiarities of mitochondrial DNA, with a decrease in the frequency of the conversion of HC in the housing estate and the promotion of the production of "XC / HC" in the housing.

Mabut, in a large number of types of housing and communal services, is polygenic, however, there can be both types of monogenic sedation. Thus, when the CYP7A1 gene is mutated with cholesterol-7-hydroxylase deficiency, which catalyzes the first stage of cholesterol conversion into the FA, an external FA deficiency is promoted. In homozygous noses of the mutant CYP7A1 gene, hypercholesterolemia and housing and communal services are expected to develop. Heterozygous lichen to cich vidhilen.

In case of mutation of the MDR3 gene (ABCB4), the code of the export pump FO on the canalicular membrane of hepatocytes, the transfer is transferred to the gum; as a result, the hypersaturation of the cholesterol and the formation of stones in different types of the biological system is promoted. In such a rank, the surplus of cholesterol in terms of admission to the Republic of Kazakhstan and FD is more often than dressings with hypersecretory cholesterol, however, it can be overwhelmed and lack of secretion of the cholesterol and PL.

I will become, if you ruin the LCD exchange, Dodatkovo drink overpopulated zhovchi XC. Substitutions of hydroxylation of cholic acid and produce up to a substitution pool with an increased pool of deoxycholic acid. Nadmіrne nadkhodzhennya deoxycholate in zhovch supervises hypersecretory HS.

Necessary to clean the shape of the stones(Figure 4).

1. Overpopulation of Zhovchi XC. The price is necessary, but not enough of the mind for stone maintenance. At a large number of hours, the amount of money in the ZhP is not large enough for the precipitation and growth of crystals of XC and growth.

2. nucleation of crystals in the monohydrate of CS, as it can be seen in the presence of provocative officials and / or non-frequent switching factors. For the occasional detection, nucleation takes place in mucin and non-glucoprotein (zokrem, immunoglobulin), and apolipoprotein A-I, A-II and deyakis in glucoprotein. It can be seen that the nucleation of a crystal monohydrate of XC and its growth, a vine in a ball of mucin gel. Zlittya bulbashok is made of crystals, which then transform into solid crystals. Further, the growth of the formation of overpriced CS of plate-part structures and bulbs will occur.

3. Decreased motility of the gallbladder - in the case of a decrease in sensitivity to cholecystokininu / abo autonomic neuropathy. Yaksho ZhP will increase the "wikidak" overpatient zhovch, stones cannot grow. In bagatokh patients from housing and communal services, the motor skills of ZhP are reduced.

Malunok 4. Etapi of illumination of HS-stones [by N.J. Greenberger, G. Paumgartner, 2015r., In Ziminami].

biliarny sludge It is possible to characterize the quality of the coating of a ball of mucous material, which can be stored in crystals of lecithin-CS, monohydrate of CS, calcium bilirubinate, mucin gel. When sludge, start to set up a siege in the most low-growth part of the ZhP, which has a very characteristic ultrasound view. For the development of bilious sludge, it is necessary to destroy the balance between viroblasts and degradation of mucin and nucleation of components in the beetle on the basis of over-saturated cholesterol and calcium bilirubinate.

Bіlіarniy sludge can be seen yak steps, before the approval of XC-stones. Notably, due to the caution, the stretching of the closest two rocks of sludge in ≈18% of the vines are known, in 60% - they know and are known, in 14% - gum stones are made, in 6% of them there are wine.

Sludge often develops in the case of impaired fast-feeling function of living quarters and associations practically with these factors, including housing and communal services (Table 1).

Osvita pigment stones

Pigment stones are often more susceptible to infection in particular Asian hikings, the Siberian population, with chronic hemolysis, bacterial contamination of female patients, sick with mucous membranes, tabular gut (winter syndrome, with ...

In case of hemolysis of the growth of the endogenous bilirubin in the zhovch, instead of it, decon'yugation in the zhovch's paths before the endogenous glucuronidase is injected.

The establishment of chemical stones also degrades the function of the dietary intake of fat in the process of adjusting the pH of the lipid and the establishment of salts to the bilirubin, as well as the development of phospholipase A bacteria, as well as catalyzing the hydrolysis.

Epidemiology

Housing and communal services are characterized by a high level of breadth in the provinces due to the ancient style of life (Europe, Pivnichna America, Russia): the price of restructuring at a rate of ≈ 10-15%. The high frequency, except for the contribution of genetic factors, can be explained by the peculiarities of the consumption of increased amounts of simple carbohydrates.

In Africa, the regions of Asia and Japan, the expansion of housing and communal services is lower - 3.5-5%.

In the epidemiological preliminaries of NANESH III, the significance of racial awareness in the frequency of housing and communal services, as well as the important addition of genetic factors in the pathogenesis of ailment, is significant. Among people of nationalities, the frequency of gallstone disease is superficially: among Mexicans and Chilean Indians, the rate of approval of gum stones reaches 45-80%.

The main factors for the development of housing and communal services:

1) vіk. Sickness of housing and communal services is clear in its core. In the lands with the western style of life, the frequency of housing and communal services in the summer reaches 30%.

However, the maximum frequency of clinical manifestations of housing and communal services is reorganized in 40-69 years.

2) become a zhіnoch. Rizik the development of housing and communal services in women is about 2-3 times, so to tie in injected estrogen to the lithogenic potential. At the same time, there is evidence of a problem in the development of housing and communal services in women and in women - to become 2.9: 1 in women and women: in the group of 30-39 years in the development of housing and communal services in women and in women - 1.6: 40-49 - 1.6; rock_v - 1.2: 1.

3) availability. The development of housing and communal services is promoted on the basis of the number of visits, especially in case of repeated visits (the rate of stone processing increases 10-11 times). During pregnancy, bilious sludge develops in 20-30% of patients, stones - in 5-12% of vypadkiv. However, the changes in the spontaneous decay of stones are re-structured after the canopy.

4) hormonal therapy in postmenopausal women is replaced (the growth of housing and communal services increases by 3.7 times).

5) acceptance of estrogens - in both articles.

6) the decline in housing and communal services has been tightened (the rise in sales is 4-5 times).

7) obesity, hypertriglyceridemia. Among individuals with the metabolic syndrome of housing and communal services, it appears in about 20% of cases.

8) diabetics

9) liver cirrhosis (risk of changes in 10 times).

10) storing lykarsky zasobіv, scho injecting on the concentration of cholesterol in the gum, the motor skills of the gallants, even before crystallization in the gums (somatostatin, fibrates, ceftriaxone).

11) shortage of thinning, bariatric involvement (efficiency of development of housing and communal services> 30%).

12) the reduction of the terminal forms of the club intestine.

13) to complete the trivial parenteral feeding.

In the last ten years, the increase in the frequency of housing and communal services among children and children is determined; best for a reason tsogo - "epidemiya of the overworldly vagi".

key picture

Symptomy, stretching

key picture

The "classic type" of a patient in housing and communal services is a woman over 40 years old, hypersthenic statues, with a history of heavy weight and canopy. One slid memory about the growing frequency of sickness of young people and to bring children with the help of a marauding body.

Housing and communal services can be asymptomatic. Klinichny show up in the development of firing or obstruction of the female nobles - with the migration of stones in the area of ​​the shyki ZhM, in Mikhurov or the zagalny zhovchny protik.

Heads cleverly show Housing and communal services are presented by attacks of zhovnoy kolka and state cholecystitis.

It is also a powerful development of cholangitis, attacks of severe biliary pancreatitis. It is possible for the development of chronic bilious pancreatitis to become a subject of discussion.

Zhovchna (biliary, pechinkova) kolka- the most frequent and characteristic manifestation of housing and communal services. The reason for the development of the kolika is the wedging of a stone into the shyka of the ZhP, for example, drinking into the ducts of the mikhura or the choledoch. Obstructions and reflex spasm occur as an intraluminal vise and manifestation of visceral pain.

In typical vipadas, gingerbreads develop in 1-1.5 years after the introduction of a fatty, greased ryzhi, or an inevitably great ossyagu, if a tricky crookedness, ). The name "kolka", which means a strong change in style, does not exactly depict the character of a cheeky colka, so it doesn’t wear it in a way that will suit the character. In the English literature, the term "biliary bill" (div. Table 5) is used for significant attacks.

Zsuv a stone can also provoke a shaking ride, nahili tuluba. The triviality of the chewing ring can become from decilkokh to decilkokh years. It is localized in the epigastriya to the right pidreber, you can go to the right scapula, in the interscapular space, on the lower thoracic ridges, in right shoulder on the right (Figure 6). Often supravodzhuyu nudota, vomiting, but not to bring lulling, and vegetative manifestations - tachііlі bradycardієyu, wines arterial vise, Paresis of the intestine, or poses on the style, changes in temperature to subfebrile values. The patient throws himself into a lazy. The attack is allowed with the introduction of spasmolytics abnormally mimic. Been shaved quickly, deeper - step by step.

Malunok 5. The indications of the bilious "colic" from the intestinal and nirkovoi for the nature of the pain.

baby 6... Localization of pain in case of ailments of female nobles and sickness.

It is not easy for a zhovchna ring to grow out at night, after a few years it is zasipannya. It’s worthwhile with the glimpses of the old days from Dania, but in the right upper quadrant of the abdomen, in the present year, it is specific for the pathology of the female nobles.

The attack of the chewing ring can be erased and repeated frequently; in some types of diagnostics, the diagnosis is formulated as "aggravated chronic cholecystitis." However, in bagatech vipadkah more correctly diagnosed the symptomatology as the manifestation of repeated rings, tied with obstruction of the shyki FM.

Yakshko attack bіlіarnoї kolіki trivaє> 6 h, next to the development of the state cholecystitis (div. Nizche). In case of adduction of syrovatous bilirubinі / abo rіvnya puddle phosphatase (LF) in syrovattsі blood traces vyklyuchati stones of choledochus. Feeling a fever with a chill when attacked by coli, which, as a rule, means the development of an accelerated state - a state of cholecystitis, severe pancreatitis, Holangita.

Gostria cholecystitis, as a rule, develops in the form of obstruction of the shyka / duct with stone. With symptomatic interruption of housing and communal services, cholecystitis is indicated with a frequency of up to 10%.

The starting point is three factors:

1) mechanical injection an extended intraluminal vice and stretching, which leads to the ischemia of the stage;

2) a cool infusion of lizoletsitin, which can be used to produce lecithin for the phospholipase, as well as other tissue factors;

3) bacterial infection, Signs of how clearly appear in 50-85% of patients (with gross cholecystitis from microflora, E. coli, Klebsiella spp., Streptococcus spp., Clostridium spp. Most often hang).

Gostriy cholecystitis turn over to fix it as an attack of bilious pain, as an increase in character right to the edge... Yak and in case of chewing, more can come into the interscapular region, to the right scapula or to the shoulder (Figure 6). In 60-70%, there are indications for the appearance in the past of certain symptoms, which spontaneously appeared. Proceedingly to accept the signs of razdratuvannya queue:

Greater localization and an increasing nature of the pain,

Strengthening with chicks and strong dyhanna,

Evidence for ileus (anorexia, repeated bloating, abdominal swelling, weakening of peristaltic noises),

characteristic symptoms, Yaki appear on palpation (table 3).

A fever of low gradations (38-39 ° C) is characteristic, however, it is possible temporal fever with chills. In a larger period - if the ducts and lymph nodes are ignited, the female can be fitted. For the duration of such an accelerated perforation of the gallbladder, the signs of poured peritonitis are not susceptible to suspicion.

V Zagalom analizі leukocytosis occurs in the blood (it grows in between 10-15x1012 / l with zsuvom), in biochemical analysis it can be detected in terms of hyperbilirubinemia (foreign bilirubin grows<85,5 мкмоль\л, прямой < 5 мг\дл) и умеренное повышение трансаминаз.

At the moment of some deprivation of key donations, the development of the state cholecystitis is easy; more important meaning of additional methods of reading (div. lower).

Table 3. Dani palpation of the abdomen with gross cholecystitis.

An unfortunate diagnosis of a goste cholecystitis is fraught with fatal rhizik poor baked goods- empiєmi, gangrene, perforation of the gallbladder, development of zhivny peritonitis. For the rate of development of gangrene, it is characteristic to alleviate the pain in the right pidrebers and increase the temperature of the patient in the presence of a severe cholecystitis, an increase in leukocytosis> 15 × 10 9 / l during the course of the therapy with an anti-inflammatory formulation, equally adequate. In the world of the build-up of a step, the gangrenous serpent can calm down the pain. A detailed view is easier to go beyond the scope of the given look.

diagnostics

The early diagnosis of housing and communal services is based on the nutritional status, anamnesis, a look around, and the identification of typical factors in the risk of sickness (div. Table 1).

To confirm the diagnosis, it is necessary to go into the methods of interchange diagnostics with the method of visualization of stones and determination of the form of ailments (Table 6).

Ultrasonic inspection of the stove and zhovchny shlyakhiv (UZD)- the method of vibration in the diagnosis of ZhKB due to the high sensitivity of the revealed stones of the ZhP, safety and wide availability. Ultrasonic scanning is not sufficiently sensitive in diagnostics of choledocholithiasis, which is abundant in what it is due to the glibin of the malignant of the terminal evidence of choledochus. An indirect sign of choledocholithiasis - enlargement of the choledochus - do not become suspicious.

When you get older on housing and communal services, you need to go to the ultrasound (class C clinical recommendations).

Ultrasonic diagnostics for patients with gosstomy cholecystitis reports div. Below in this section.

With ultrasound, you can start with the titles “ non-functional "ZhP-Make the minimum number of wrinkles (wrinkles), but, navpaki, stretching, and do not speed up when looking at a wrinkle.

Allowing the appearance of gum stones when there is enough calcium in them (10-15% of cholesterol and close to 50% of pigment stones are produced by the cyme method). Radiography also stagnates in the development of emphysematous cholecystitis, porcelain gallbladder, venous gallbladder, paresis of gallbladder.

cholecystography Oral contrasts are stagnant in an hour even more rarely, call for an assessment of the passage of the michura duct and the rapidity of the ZhP.

Cholangiography with internal contrasts it is also practical not to get stuck due to the lack of clear contrast.

Throughshkirna transhepatic cholangiography (CHCG) is an alternative method of contrasting the bilary tree in vipads, if the methods (MR-KhPG, ERHG) are unsuitable. Punctuation of the biliary tree, as a rule, is carried out in the 10th or 11th intercostal spaces (є risik pleura). Transfusion access is not high risik round of zhovchi. Signal frequency of important procedures becomes 2-4%.

Endoscopic retrograde cholangiography (ERCH)- an invasive method, during which cannulation of the great papilla is carried out with the contrast of the common bile duct. In case of concrement / іv in the common bile duct, endoscopic papillosphincterotomy with lytoextraction can be performed one hour. ERHG, due to its technical folding and traumatism, doesn’t get stuck only for diagnostics (in case of adolescence for choledocholithiasis). ERHG in the course of planned endoscopic papillosphincterotomy with the help of securing access to the papillotome and visualization of the process.

With X-ray dosligens with contrast, you can start so titles "Connections" - do not allow contrasting - ZhP... The reasons for which you can serve:

Totally zapovnennya ZhP to stones,

Lack of duct due to stone blockage or stenosis,

Sclerosis, morbidity, calcification of the gallbladder.

Magnetic resonance cholangiopancreatography (MR-CPG) Lack of high diagnostic value in the development of choledocholithiasis (close to 90-95%), however, stones in size<3 мм могут не обнаруживаться. Это исследование нельзя проводить пациентам с кардиостимуляторами/дефибрилляторами, несовместимыми с проведением МРТ, что служит существенным препятствием, особенно в когорте пожилых больных.

Endoscopic ultrasound dosage (endoscopy) Pancreatic-bilious zones can be found to have a higher diagnostic value in the development of choledocholithiasis (close to 98%), lower MR-CPH, so as to allow the appearance of even more cold, more cold conditions The interconnection of the stagnation method is its invasiveness and the possibility of assessing the duct system only in the area of ​​inflow into the 12-p.kishka.

Computer tomography not allowing to judge with sufficient credibility about the appearance of stones in the galls, so that there are stones, but to get enough calcium and glaze X-ray exchanges (no more than 50%).

Bіlіoscіntіgrafіya - radioisotopic up to 99m Tc with specific fіlnіodіacetic acids (HIDA, DIDA, DISIDA etc.) The presence of a sufficient visualization of gallbladder in case of normal visualization of the distal part of the duct, can be inflicted on the obstruction of the duct, or chronic cholecystitis or undergoing cholecytectomy.

Table 6. Instrumental methods of diagnostics of gallstone disease.

* ZhP - zhovchny mikhur

Instrumental methods in diagnostics of the State Cholecy Institute

The emergence of a state of the art cholecystitis cannot be reversed without going into pre-existing methods., Zokrema UZD і cholecystostocyntіgraphіі (їх sensitivity of the warehouse - 88% і 97%, obviously).

Signs of the State Cholecystomy Institute for the data of pre-treatment methods:

Ultrasonic scanning: soreness when the sensor is compressed without the middle in the projection of the gastrointestinal tract ("ultrasonic symptom Murphy"), the appearance of the line near the ventricular cavity, and the enlargement of the wall (≥4 mm). Naybіlsh specific and superior z cich sign

- "ultrasonic symptom of Murphy", the evidence of the draining of the wall and the appearance of the birth can be summed up by other reasons (for example, ascites);

Cholecystoscintigraphy: the visibility of the gallbladder (in case of the occlusion of the duct).

Differential diagnosis

Differential diagnosis of pain in the right upper quadrant of the abdomen, which is typical for housing and communal services, is very difficult for an hour. Table 4 shows the main nosological forms, and also the next development. Especially relevant in business ischemic heart ailments.

Table 4. Differential diagnosis of pain in the right upper quadrant of the abdomen.

An attack of crustaceans is necessary to differentiate from the manifestations of the lower myocardial infarction, to be repaired by an attack of pancreatitis, as well as intestinal infarction. That is why it is important to improve the physical and mental health of the patient from the assessment of all systems.

For viklyuchennya myocardial infarction, especially in individuals with factors of ІХС risk, to carry out a complete restoration of the EKG.

Attack to pancreatitis is characterized by the appearance of an intense pain of an operative character, repeated bluetongue.

With intestinal coli, defecation and release of gases, as a rule, cause pain to relieve.

Skargi on non-fatiguing swelling blistering (discomfort) in epigastric dileantsi, dyspeptic manifest, haircut, abdominal pain when you take a fatty one do not follow the bile; tsi symptoms are often seen in housing and communal services, but not specific to her. Some symptoms are not infrequently identified as "foul tolerance of fatty or overuse" and associated with impaired reaction to enterogormone - cholecystokinin and YY-peptide.

If typical bilious pain is evident, it is not necessary to carry out ultrasound examination (UZD) of organs in the empty empty space. The ultrasound scan is 99% specific for the discovery of gum stones, and it is safe and easy to achieve a cheap method of dosage. However, in a small part of the patients, who are unaffected by the manifestation of typical bilious pain, the stones cannot be penetrated. With a primed suspicion for the manifestation of the very bilious pain, it is possible to suspect a dyskinesia of the female nobles. The dyskinesia is characterized by a low fraction of fast gallbladder (<50%) по данным холецистосцинграфии с холецистокинином.

In the table 5, there are indications of signs, which can be used for the differentiation of the State Cholecy Institute from among those who are ill.

Table 5. Signs that allow differentiation of cholecystitis from other patients.

Likuvannya beyond the cordon

Take a lykuvannya in Korea, Izrail, Nimechchin, USA

Otrimati the consultation on medturism

lykuvannya

principle of liking

With asymptomatic overruns, the best tactics are thoroughly adjusted to look at the patient without active treatment (class C clinical recommendations). When the symptoms are on the rise, the development of symptoms is either slower, if you require surgical treatment, to reach a low level (1-2% per ric).

Sposib life, harchuvannya

Education of normal mass and rational style The calorific value of the race is to blame for being in peace, for taking a shot - for the shot (5-6 times a day with interruptions not longer than 4-5 hours, with a twist of the night). Dottrimuvatisya style of food, filled with food fibers (fresh fruits and vegetables), cereals (grain bread, oats, brown rice, products with hanging), cinnamon fermented and mixed products, in the middle of meat in the middle іndichtsі (no shkіri), ribi (no more bold). Fermented milk products are more vibrant than the reduction in fat, and the implantation of dairy products to the minimum. A slid of unique greased herbs, smoked meats, vipychki and іzhі, a lot of simple carbohydrates (the rest of the rizik stoneware). Regular physical activity of additional assistance to improve the growth of mass.

surgical treatment

Cholecystectomy is the main method of surgical treatment of housing and communal services, which prevents clinical symptoms. Cholecystectomy is not only for the accelerated state of cholecystitis, but for the development of cancer of the gastrointestinal tract in a given period.

In numerical robots, it has been shown that cholecystectomy carries a low risk of unpleasant weeds, and the risk of recurrence of symptoms with this method of treatment is the least. Laparoskopіchna tehnіka Got yavnі perevagi in porіvnyannі of operatsієyu vіdkritim access in bagatoh vіdnoshennyah: Mensch pomіtnogo kosmetichnogo defect bіlsh nizkoї vartostі, bіlsh Rann vіdnovlennya pratsezdatnostі, nizhchoyu letalnostі, Mensch virazhenoyu stage poshkodzhennya tkanin i bolyu in pіslyaoperatsіynomu perіodі i bіlsh short perіodu perebuvannya in statsіonarі.

In the last few years, the technique of one-port laparoscopic cholecystectomy is developing - through one trocar access in the paraumbilical area, which gives a minimal cosmetic effect. Operation through a single-port access is most optimal in cases of persistent chronic cholecystitis.

Shown before cholecystectomy is presented in table 7.

If necessary, carrying out cholecystectomy per hour of vaginosti(In the case of the development of the state of cholecystitis, pancreatitis, or the unhappiness of living in an adequate amount through the appearance of symptoms) the risk of operative involvement for the mother and the fetus is the same in the other trimester.

Table 7... Indicated before cholecystectomy and optimal terms for operative engagement (if there is a problem with evidence).

* Note. In Russia, the practice of carrying out cholecystectomy from the drive of discinesis of young people ("acalculous cholecystopathy") has not yet gone down, the operation is carried out only in some cases.

In the rest of the world, in the world of perfection of operational technology, there have been accepted earlier contraindications to laparoscopic cholecystectomy. Disease, laparoscopic surgery is not recommended for patients with gross cholecystitis, in summer, for chronic obstructive ailments, and for chronic obstructive ailments, for liver cirrhosis of class A and B for Child-Pugh (aley) not for severe obesity in case of presence in the anamnesis of cases of abdominal involvement.

The need to switch to an operation with an open access with laparoscopic intervention in 5-25% of cases, and the most common reason for this is the folding of the establishment of anatomic structures.

According to the meta-analysis, the mortality rate for laparoscopic involvement is 8.6-16 per 10,000, with open access - 66-74 per 10,000 patients. At the same hour, the frequency of the occlusion of the zhagary duct during laparoscopy was 36-47 per 10,000 and 19-29 per 10,000 patients, for example.

through the cholecystolitotomy carried out in the minds of anesthesia and fluoroscopy control and ultrasound. For a puncture of the cranial wall, a small growth of the life-cycle is carried out, through which a visualization of stones is carried out for additional contact electrohydraulic or laser lithotripsy. Farther, the catheter is blown out in the middle of the microscope, allowing the zhovchi turn to start. Visoka frequency of recurrences of stone processing. Perevagi before cholecistectomy are not shown. Vtuchannya is carried out only in okremikh vipadkah.

Cholecystostomy (including minor cholecystostomy) Visiting the edge of the country, only in special surroundings - to the patients with a very high operative rizik, who will be responsible for the life shows, which is the fault of the most traumatic one. Anesthesia is carried out during the course of anesthesia. When a purse-string suture is applied, an aspiration is carried out in place of that visible stones. With a few shortcomings, it’s hard to serve the inability of finding and seeing the stones in them, and the ability to miss out on the fast track - to repair gangrene, calculi of the root duct, cholangitis.

Understanding about postcholecystectomy syndrome

In 10-15% of patients who underwent cholecystectomy, they also have more symptoms on the side of the etching organs (babies 7). For the recognition of such stanіv inіdі vikorystovuyut zbіrne understand "post-cholecytectomy syndrome". From a practical point of view, it is necessary to use a unique form of such a publicity, so that in 95% of cases it is possible to find the correct reason for the symptoms, and, apparently, vibrate the correct tactics of treatment.

babies 7... The frequency of manifestations of "postcholecistectomy" disorders [data from statistic Jensen SW. Postcholecystectomy Syndrome. Internet site

http://emedicine.medscape.com/article/192761].

See early and early form of postcholecystectomy syndrome. Before the first to carry surplus stone ducts abo choledochus, cholangitis, vestiges of intraoperative zhkogennya zhovchny ducts, viti cannula zhovchi. To others - a relapse of stone release in the ducts, strictures, inflammation of the duct / gallbladder, stenosis of the Vater papilla, dyskinesia of the sphincter Oddi, education of neurinomas, as well as the manifestation of congestion of suspicious organs, intestinal tractitis, gastrointestinal reflux disease ischemia of the intestine), which should be taken beforehand before the operation.

The development of cholecystectomy diarrhea can be accompanied by damage caused by operative injuries, as well as by changing synchronization of appropriate gum acids with intravenous diarrhea ("holographic" diarrhea). In the majority of patients with cholecystectomy, the normal rhythm of the secretion of the female is renewed. Zhovchny acid and natchestyuyutsya in the proximal part of the small intestine, and when the intake of peristalsis is peristaltic, the stench quickly permeates in the distal viscera, develops into reabsorption.

The plan for the provision of patients with "postcholecystectomy syndrome" to include, in addition to routine dosages, described more recent methods of interchange diagnostics, so that a high level of detail is shown. In case of chronic diarrhea, the situation is carried out according to the traditional plan for a whole syndrome.

minimally invasive engagement

Contact chemical litholysis method- in addition to the introduction of methyl-tert-butyl ether into the ZhP, as well as the distribution of stones - to be stashed in the vicinity of the universities of Nimechchin, the Italian and the United States with the permission of the local communities. Methyl-tert-butyl ether is not registered as a drug in the state region outside the cordon, not in Russia. Yogo introduction, fallen from the access to the stone, carry to finish the high risik accelerated. The frequency of recurrences of stone processing can also reach the temple. On the current day in Russian clinics, contact literature is not practiced.

Throughshkirna shock-khvilova lithotripsy- a non-invasive method, in case of any local supply of stones with high energy (electro-hydraulic, electro-magnetic or electro-electric) to produce stones. Lithotripsy can be stored if there are less than 3 stones in the gallbladder with an extra diameter<30 мм «всплывающего» типа и при условии сохранения функции ЖП (сокращение ЖП на 50% по данным сцинтиграфии).

As a result of the interconnection of minds, when the method is effective, it is effective to achieve a high frequency and acceleration (colka, gostry cholecystitis, pancreatitis, choledocholitas with the development of mechanical zhovtyanitsa, micro- and macrohematuria). Without additional treatment with ursodeoxycholic acid, the frequency of recurrences of stone removal in the nearest 1-2 rocks is 50%.

Conservative lіkuvannya housing and communal services

In housing and communal services, you can use ursodeoxycholic acid (UDCA) preparations for oral cleaning of stones. However, there is a stench of effective deprivation in the interconnected part of patients (about 10% of all patients in housing and communal services).

UDCA decreases the amount of cholesterol and also, apparently, the lamellar crystalline phase, like the extracts of cholesterol from stones. The dose of UDCA for the administration of housing and communal services in a warehouse is 10-15 mg / kg of mass per day.

The clinical efficacy of the therapy with preparations of gum acids is shown in the presence of clinically significant (infrequently due to bilious pain) X-ray-insensitive gum stones with a size less than 15 mm, due to the saving of the loss of life. The highest frequency of response (> 70%) is attainable in patients with malimi (<5 мм) флотирующими рентгенонегативными камнями. В этих случаях при назначении УДХК в течение 3 месяцев удается достичь уменьшения выраженности билиарной боли более чем у половины пациентов. При приеме УДХК в дозе 10 мг/кг массы тела в день в течение 1 года растворение камней происходит примерно у 60% пациентов. Рецидивы в ближайшие 5 лет наблюдаются в ≈25% случаев. Поэтому наиболее целесообразно ограничивать назначение УДХК случаями, когда у пациента имеются противопоказания к оперативному лечению или он не дает согласия на проведение холецистэктомии (класс С клинических рекомендаций).

Lіkuvannya UDKhK to carry out under control of ultrasound examination of skin 3-6 months. Visibility is a sign of a change in the number of stones and changes in stones after 6 months.

Pigment stones are not accepted by the UDCK.

The drugs of chenodeoxycholic acid are not stagnant in Russia at a given hour.

For bilingual collection It is possible to fix antispasmodics of different classes, which can be administered parenterally for the purpose of rejecting a shvid effect.

We will push the spasmolytic diyu to navigate when we take it all the way to the middle. hyoscina butylbromide- antispasmodic of selective N-, M3-cholinoblokuyuchu diy. Numerous pre-adolescents have been diagnosed with a drug in the treatment of bilious pain, as well as abdominal pain in the first place (the effectiveness of confirmation in meta-analysis). The spasmolytic action of the gostin has been brought to the sphinkter of Oddi. The effect of the state of mind for a patient in the middle insisted on the 15th grade, which is important for the quick relief of painful biliary pain. Dose regimen: take 10-20 mg "for vimoga" all the way, either in suppositories, or in a course of administration of 10-20 mg 3 times a day until 10-30 days. Klas V klinicheskikh recommendations in the relief of bilious pain.

For the suppression of dyspeptic symptoms, Often, substandard housing and communal services ("nasty tolerance of fatty and ryasnoi"), spasmolytics, frogmen, and also hymecromon, which Volodya cholecystokin-like

Alverina + simethicone the workers of the combined warehouse do not only suppress the spasm and pain (alverina, selective spasmolytic), but rather for the manifestation of the optimal dose of the antifoam in the warehouse, the optimal dose of antifoam suppressing meteorism, the domineering patrons. Dozing regimen: reception "for vimoga" 1 tab. (60 mg + 300 mg) all the way in case of uncomfortable symptoms and conditions, or a course of treatment for 1 table. 2-3 times a day before going for a stretch of 14-30 days or more trivially (class B in clinical recommendations in stopping flatulence).

hymecromone- high-selective spasmolytic of the sphinkter Oddi, a synthetic analogue of umbelliferon, which takes revenge in the fruits of anis and fennel, since it has become stagnant for a long time as spasmolytic. Hymekromon nadaє cholecystokininopodobljuyuyuyu injection on sphinkter Oddi. In the last few years, hymecromone has shown significant efficacy in relieving bilious pain. The drug has no contraindications for housing and communal services, cholecystolithiasis. Diya gimekromon realizes only on the level of female nobles; Absorption into the systemic bloodstream does not change 3%, but in what way I will explain the high selectivity of the action on the sphinkter of Oddi.

The sphinkter of Odd is relaxed and polypsychiatric in the 12-palate intestine, hymecromone can reduce the lithogenicity of the cow. It is possible to add to the therapy of UDCK with the help of razchinennya gum stones.

The dosage regimen of hymecromone: taking 200-400 mg "for vimoga" all the way in case of uncomfortable feelings, or a course of treatment of 200-400 mg 3 times a day for one day to another for 14-30 days or more trivially. Klas In key recommendations.

sucking prokinetics(Domperidone, іtoprida, trimebutin), which is injected into the upper part of the intestinal tract, during housing and communal services it is primed, such patients rarely see dyspeptic symptoms, and motor skills of the intestines

trimebutin as an agonist of peripheral μ-, κ- and δ-opiate receptors, it is prokinetic and immediately viable spasmolytic effect, which gives the power of a universal modulator of motility of all types of activity in the herbal tract. Before you show it, trimebutin shvidko (lasting a year) assimilates the stomach and dyspeptic problems in case of ailments of ZhP (class C of key recommendations). The dosage regimen of trimebutin: a course of administration of 100-200 mg 3 times a day, regularly for a period of 30 days. for more than a trivial hour. The drug is well tolerated.

Rizik development of housing and communal services in the population without gum stones. Naybіlsh high risik (close to 20%) is susceptible to "porcelain" ZhP, which is shown in the presence of prophylactic cholecystectomy.

babies 8... Natural surplus of housing and communal services (the appearance of symptoms and development is accelerated by the hour).

information

Dzherela and Literature

1. CLINICAL RECOMMENDATIONS OF THE RUSSIAN GASTROENTEROLOGICAL ASSOCIATION
   1. 1. Ivashkin V.T., Lapin T.L., ed. Gastroenterology: national curriculum - M .: GEOTAR-Media, 2008. - 700С. 616.3 G22 6. 2. Kalinin A.V., Khazanov A.I., ed. Gastroenterology and hepatology: diagnosis and treatment: a key for patients. - M .: Miklos, 2007 .-- 600 p. 616.3 G22. 3. Ivashkin V.T., ed. Clinical recommendations. Gastroenterology- M .: GEOTAR-Media, 2008 .-- 182p. 616.3 K49 12. 4. Ivashkin V.T., Lapin T.L., Okhlobistin A.V., Bueverov A.O. for practical users - M .: Litterra, 2008. - 170S. 616.3 H20. 5. Rational pharmacotherapy in hepatology: a key for practicing drugs / pid zag. ed. V.T. Ivashkina, A.O. Bueverova. - M .: Litterra, 2009 .-- 624p. 615.2 P27. 6. ACOG Committee on Obstetric Practice. Guidelines for diagnostic imaging during pregnancy. ACOG committee opinion no. 299, September 2004. Obstet Gynecol. 2004; 104: 647-51. 7. Alimoglu O, Ozkan OV, Sahin M, Akcakaya A, Eryilmaz R, Bas G. Timing of cholecystectomy for acute biliary pancreatitis: outcomes of cholecystectomy on first admission and after recurrent biliary pancreatitis. World J Surg. 2003; 27: 256-9. 8. Attili AF, De Santis A, Capri R, Repice AM, Maselli S. The natural history of gallstones: the GREPCO experience. The GREPCO Group. Hepatology. 1995; 21: 655-60. 9. Berger MY, Olde Hartman TC, Bohnen AM. Abdominal symptoms: do they disappear after cholecystectomy?. Surg Endosc. 2003; 17: 1723-8. 10. Byrne MF, Suhocki P, Mitchell RM, Pappas TN, Stiffler HL, Jowell PS, et al. Percutaneous cholecystostomy in patients with acute cholecystitis: experience of 45 patients at a US referral center. J Am Coll Surg. 2003; 197: 206-11. 11. Huang CS, Lein HH, Tai FC, Wu CH. Long-term results of major bile duct injury associated with laparoscopic cholecystectomy. Surg Endosc. 2003; 17: 1362-7. 12. Leitzmann MF, Giovannucci EL, Rimm EB, Stampfer MJ, Spiegelman D, Wing AL, et al. The relation of physical activity to risk for symptomatic gallstone disease in men. Ann Intern Med. 1998; 128: 417-25. 13. Nakeeb A, Comuzzie AG, Martin L, Sonnenberg GE, Swartz-Basile D, Kissebah AH, et al. Gallstones: genetics versus environment. Ann Surg. 2002; 235: 842-9. 14. Papi C, Catarci M, D'Ambrosio L, Gili L, Koch M, Grassi GB, et al. Timing of cholecystectomy for acute calculous cholecystitis: a meta-analysis. Am J Gastroenterol. 2004; 99: 147-55. 15. Puggioni A, Wong LL. A meta-analysis of laparoscopic cholecystectomy in patients with cirrhosis. J Am Coll Surg. 2003; 197: 921-6. 16. Syngal S, Coakley EH, Willett WC, Byers T, Williamson DF, Colditz GA. Long-term weight patterns and risk for cholecystectomy in women. Ann Intern Med. 1999; 130: 471-7. 17. Testoni PA. Acute recurrent pancreatitis: Etiopathogenesis, diagnosis and treatment. World J Gastroenterol. 2014 Dec 7; 20 (45): 16891-16901. 18. Tham TC, Vandervoort J, Wong RC, Montes H, Roston AD, Slivka A, et al. Safety of ERCP during pregnancy. Am J Gastroenterol. 2003; 98: 308-11. 19. Trowbridge RL, Rutkowski NK, Shojania KG. Does this patient have acute cholecystitis?. JAMA. 2003; 289: 80-6. 20. Tse F, Liu L, Barkun AN, Armstrong D, Moayyedi P. EUS: a meta-analysis of test performance in suspected choledocholithiasis. Gastrointest Endosc. 2008; 67: 235-244. 21. Vetrhus M, Soreide O, Solhaug JH, Nesvik I, Sondenaa K. Symptomatic, noncomplicated gallbladder stone disease. Operation or observation? A randomized clinical study. Scand J Gastroenterol. 2002; 37: 834-9. 22. Ward S, Rogers G. Diagnosis and management of gallstone disease: summary of NICE guidance. BMJ 2014; 349.
   rіven Type of tribute 1a

   Prove that randomized dosages are recognized in meta-analyzes.

   1b

   Prove that it is the minimum in one randomized message.

   2a

   Prove that otrimanі as a minimum in one well-planned controlled dosage without randomization.

   2b

   Prove that it is a minimum in one well-planned, experimental, pre-existing type.

   3

   Prove that, in good planning, non-experimental preliminaries, such as porous, correlative preliminaries and inventories of clinical

   abo

   a group of proofs, which includes the results and the level of results, estimates of 1+, directly to the whole population and demonstrates the out-of-the-box quality of the results

   V

   A group of proofs, which includes the results of a pre-test, an assessment of 2 ++, without an average rate of achievement of the whole population and demonstrates an out-of-the-box performance of the results, for example, extrapolation of proof from a pre-assessment of 1+

   C

   A group of proofs, including the results of a pre-test, an assessment of 2+, without an average rate of achievement of the whole population and demonstration of the extraordinary efficiency of the results, for example, extrapolation of proof from a pre-assessment of 2 ++

   D

   Prove Rivnya 3 or 4

For a quote: Seleznova E.Ya., Bistrovskaya O.V., Orlova Yu.M., Koricheva E.S., Mechetin T.A. Algorithm for diagnosing the disease of gum disease // RMZ. 2015. No. 13. P. 730

Zhovchnokam'yana ailment (housing and communal services) is a complex factor and a failure of the hepatobiliary system, which is characterized by a singing clinical picture, the loss of cholesterol (HC) and / or

Housing and communal services are awaiting 10 to 20% of the overgrown population. Women get sick more often. 2/3 patients may have cholesterol stones.

Clinical stages:

I - cob (pre-stone);

II - molding of gum stones;

III - chronic cholecystitis;

IV - accelerated.

1. Ethiology

Most ailments in housing and communal services develop as a result of a complex infusion of ineffective factors, including:

1. Diet: too much carbohydrates and fatty fats, lack of tall fibers and bricks; low-calorie life with a fast reduction of mass; the destruction of the mode of eating (priyom їzhі at nіch).

2. Constitutional: slump, hypersthenic type of constitution.

3. Medical: chronic diabetes, dyslipoproteinemia, liver disease, intestines, parenteral disease, intestinal dysmotor, infection of the bilious tract, hemolytic anemia, trivial parenteral disease.

4. Pharmacological: contraceptive drugs, fibrati, diuretics, octreotide, ceftriaxone.

5. Social-hygienic: malignant alcohol, kurinnya, hypodynamia.

6. Psychological: parts of stressful situations, conflicts in the homeland and / or on robots.

7. Vagіtnіst, zhіnocha to become, superfluous masa tіla.

2. Pathogenesis

At the same time, the appearance of 3 main pathological processes - overpopulation of cholesterol, destruction of the dynamic response and anti-nucleating factors and decrease in the speedy function of the stomach.

An important form of cholelitis є chronic biliary deficiency, zoomed with a deficiency of gum acids. Increased factors є: impairment of enterohepatic circulation of zhovchic acids, psychovegetative dysfunction and neurohumoral dysregulation and infection.

3. Diagnostics

Diagnosis of housing and communal services is carried out on the basis of a clinical picture, data from laboratory and instrumental methods of pre-examination (screening method - transabdominal ultrasound) (Scheme 1).

clinical symptoms

Klinichna picture at the stage of BS

Biliarny sludge (BS). This term means whether the heterogeneity of women, as spontaneous in the case of echographic preliminaries. Illness at the th stage can be asymptomatic, supravodzhuvatsya dyspeptic disorders or pains, which can be localized in the right side of the ribs (syndrome of "right ribs").

Clinical picture at the stage of cholelitis

1. Asymptomatic stone carriage (latent surplus of housing and communal services).

It occurs in 60-80% of ailments with stones in the gallbladder, and in 10-20% - with stones in the gum ducts. Zhovchnі stones є vypadkovuyu znakhіdkoyu with obsozhennі z drive іnіhіvoryuvans. The period of latent masonry in the middle trivia was 10-15 years.

2. Bolova form with typical chewing gums. In the outlying population of housing and communal services ills, there are 7-10% of populations. Rapto emerge to pick up and beckon to be periodically repeated by the large attacks of the pechinkovo ​​(zhovnoy) coli. An attack is provocatively provoked by a gibberish in a child or physical navanazhennyam, and sometimes develop for no apparent reason. Mechanism of the diagnosis of pectoral colitis is the most frequent of dressings for damage to the bile outflow from the gallbladder (spasm of the duct, obturation of it with stone, mucus) or for the loss of incontinence of the gallbladder along the back stone of the gallbladder (spasm of the gallbladder) For the data of surgical hospitals, a form is given to get involved in the most frequent manifestation of cholelithiasis.

3. dyspeptic form. The frequency of emergence of the housing and communal services formation rises in wide fringes (30-80%), and the frequency of occurrence of the development of the housing and communal services is based on the fact that the history of the disease is relatively clear. For the general formation of the so-called “syndrome of the right pidgebury” at the sight of gravity, discomfort in the right pidgebury, tied or not tied with priyomas. At the end of the day, 1/3 of the ailments are found in the rot.

4. Come under the mask of those who are ill.

Angina pectoris form. Yak cholecystocardial syndrome was described for the first time in 1875 by S.P. Botkinim. In case of a form of pain, which occurs with a peppered number, it expands to the area of ​​the heart, provoking angina attacks. Call us for cholecystectomy against angina pectoris.

Trida Saint. The study of housing and communal services with diaphragmatic grits and diverticulosis of the intestine, described by Ch.E.M. Saint in 1948 r The pathogenetic link of the components in the three is unclear, perhaps, read about the genetic defect.

accelerated cholecystolithiasis

Gostry cholecystitis. Among the ailments with cholecystitis, 90% of the ailments are stored in ZhKB. Most often sposter among the lithians. With gross cholecystitis, pathological changes are detected in the stage of gastrointestinal tract (sclerosis, impaired blood circulation, etc.). Take off the mechanical development of the mucous membrane with concrements, the destruction of the gum behind the rakhunok of the partial abnormal obturation of the Mikhur duct. Infection (kishkova or synogniina stick, enterokoki and in.) At ultrasonic scanning, the trisharove of the ZhP stinki will appear.

Chronic calculous cholecystitis is the most rapid development of housing and communal services. Contrary to often in viglyadі dyspeptic form, zhovchnі coli develops rarely. When ultrasonic scanning is performed, it is not possible to show signs of urinary tract infection.

Gallbladder inclusions are one of the most common accelerated cholecystolithiasis. The main reason for the inclusion of gallbladder is that it is wedged into the stone calculus, and more - the clot of the putty-like gum (ZG). A friendly bureaucrat є shy cholecystitis.

Dropsy of the gallbladder develops as a result of obstruction of the gallbladder duct driven in by calculus or a clot of gallbladder; When there is a lot of ZhP, it’s going to grow in volume, and the wall of it groans. On palpation - an increase in the gastrointestinal tract, elastic, painless (Courvoise symptom). Diagnose for an additional ultrasound scan, and some additional computer tomography (CT).

The empire of ZhP develops on the included ZhP as a result of the admission of infection. Clinical manifestations in some cases can be smoothed, especially in lithians, and sometimes it can be seen as an internal abscess.

Phlegmon of stinky ZhP is the result of a state of cholecystitis. Often supravodzhutsya formations of developmental fistulas. Diagnostics is based on data from clinical, laboratory and instrumental dosages (ultrasound, CT).

Perforation of the gallbladder is associated with transmural necrosis of the gallbladder wall as a result of the decubitus ulcer and superficial fistula formation.

Gum fistulas are formed in case of necrosis of the gallbladder wall and develop on:

a) bіlіodіgestіvnye (cholecystoduodenal, cholecistogastric, choledochoduodenal and in.);

b) bіlіobіlіarnye (cholecystocholedochial, cholecystohepatic).

Cholangitis develops in case of inflammatory bilious fistulas.

Bilarny pancreatitis is caused by a breakdown of the bile outflow and pancreatic secretion, which is caused by a breakdown of a stone, or a BS with a ZhP, or a zagalny zhazhnoy duct.

Syndrome of Miriztsi develops as a result of wedging concrement in the gallbladder clump and is caused by the ignition process, as a result of which there may be a slowing down of the root canal, with a further development of the mechanical zhovtyanitsa.

Intestinal laxity, lumpy with gum stone, grows even worse (1% of all types of perforation and intestinal laxity). It develops in cases of pressure ulcers and subtle perforation of the genital mucosa by a great calculus and getting into the small intestine. Intestinal blockage with a stone appears in the most sound part of the small intestine, clogging in 30-50 cm proximal to the ileocecal flap.

Cancer of the gallbladder. In 90% of cases of hypertension, cholecystolithiasis occurs. Especially high risik of malignization of vinikє with trivial masonry (more than 10 rocks).

choledocholithiasis

The frequency of choledocholithiasis in the housing and communal services of the warehouse is 15%, in the abducted and old man - 30-35%. In principle, the vision of 2 types of choledocholithiasis: residual and recurrent. Recurrent concretions are invaded, the establishment of strictures, stenosis of the great duodenal papilla (OBD) and the obvious side material (seam material) in the zaghalny zhovchny prototype.

Clinically, choledocholithiasis can be asymptomatic or asymptomatic, or symptoms (zhovtyanitsya, fever, pain syndrome).

Transabdominal ultrasound scanning allows the diagnosis of PROTOCOL stones in 40-70% of cases. It was reasoned that some of the ailments should not be exposed to the gallant gallbladder through flatulence; In cich ultrasound situations, add endoscopic retrograde cholangiopancreaticography (CPG). Slid vrahovuvati contraindicated until late, the ability to develop faster, as well as a low frequency of occurrence in the choledochus of stones with a diameter of less than 5 mm.

Endoscopic ultrasonography (EUS) is the "gold standard" for diagnostics of choledocholithiasis, the sensitivity of which is 96-99%, and the specificity is 81-90%.

It has been shown that the blood is biochemically advanced in terms of the activity of alanine aminotransferase (ALT), aspartate aminotransferase (AST), phosphatase (LF), γ-glutamyltranspeptidase (GGTP).

On'єactive (physical) obsozhennya

MAH ORIENTVNY DIAGNOSTIC MEANING. With housing and communal services, accelerated treatment with cholecystitis, there may be positive symptoms: Ortnera (pain during post-treatment on the right of the costal dysfunction), Zakhar'ina (the manifestation of ailment during palpation or percussion of the pain in the middle of the period of life) percussion on the anterior cephalic stintsi in the projection of the ZhP), Murphy (manifestation at the height of the sickness at palpation at the point of the ZhM), Georgievsky - Musse or the right-handed phrenicus symptom (the obviousness of the sickness of the sickness) Symptom Courvois - palpation is the start of an increase, stress and painful gallbladder, which is indicative of a blockage of the backbone duct, accumulated with choledocholithiasis, swelling, swelling, suffering from sufferers.

Clinical value of the points of Mackenzie, Bergman, Yonos, Lapinsky, which allows to carry out a differential diagnosis of pathological undergrowth.

Laboratory methods for follow-up

Obov'yazkov_. Clinical blood analysis, extraal blood analysis, dissection diastasis, biochemical blood tests (extracellular bilirubin, extracorporeal blood cells, glucose, amylase, extracorporeal bloodstream, ALT, GUPT factor, LF) Analysis of blood for RW, IL, viral markers (HBsAg; anti-HCV). Lіpіdny spectrum krovі of viznachennyam koefіtsієnta aterogennostі (CH lіpoproteїnіv visokoї schіlnostі, cholesterol lіpoproteїnіv nizkoї schіlnostі, triglіtseridi, fosfolіpіdi) bіohіmіchne doslіdzhennya zhovchі, otrimanoї with duodenal zonduvannі (XC, zhovchnі acid fosfolіpіdi of obchislennyam cholate-cholesterol koefіtsієnta i fosfolіpіdno-cholesterol koefіtsієnta) ...

In case of unresolved interruption of housing and communal services, laboratory indicators, as a rule, do not change. In 30-40% of the cases when attacked by gingerbreads, the increase in the activity of syrovatous transaminases is indicated, in 20-25% - the level of alkaline phosphatase, GGTP, in 20-45% - the level of bilirubin. As a rule, after 1 day. when attacked, the indicators return to normal. If the disease is accelerated by calculous cholecystitis, it means leukocytosis and an increase in SHOE.

Dodatkov_. Morphometric dosage of zhovchi (crystalography) by the method of polarization microscopy for determining the features of the structure of zhovchi. Changes in the morphological picture of women are being repaired already at the early stage of housing and communal services, the optical structure of crystals changes in fallowness from the past.

Instrumental methods of follow-up

Transabdominal ultrasonography is the main diagnostic method. In most cases, I will have a clear visualization of all types of households and women’s nobles. Allowing the vivification of the growth, the form of the gastrointestinal tract, the structure and the structure of the tongue, the nature of the intraluminal, as well as the change in the position of the sick and the manifestation of local pain in the case of an instrumental palpation ultrasonography. In a large number of types, before the last few years, there are available small or lateral ducts, allowing you to reject the type of width, stanis, manifestations of concretions, healthy life and other pathologies. Sensitivity to the warehouse method is 37-94%, and the specificity is 48-100%.

In normi ZhP, there are no more accurate contours, but it is rather uniform. With BS you can see: sieges of sieges at viglyadі other particles; rosharuvannya zhovchі based on the statements of the horizontal rіvnya "Ridina - Ridina"; the establishment of lumps of echogenicity, to vindicate or fix them to the wall of the ZhP; total adjustment of echogenicity (coming close to echogenicity of liver parenchyma) (HL). Slid vrahovuvati, so HL will accelerate accurate diagnostics, since K. It is recommended to see these forms of BS:

• microlithiasis (suspension of hyperechogenic particles: dots, singly or multiple, change, but do not give an acoustic type);
• ZZh (non-homogeneous zhvch with the appearance of delianoks, which is close to echogenicity to the parenchyma of the stove, changes from those fixed to the stinka zhp);
• preparation of dietary supplements with microlites; with a lot of microlitics, you can be immediately in the warehouse with a bunch of healthy food, or in empty food.

EUS. Allowing a greater clear assessment of the postoperative ducts on all protrusions, the BDS area, clarify the nature of pathological changes in the life course. It is possible to significantly change the number of diagnostics ERCP in case of adolescence for choledocholithiasis, if it is introduced into the clinical practice of EUS. In ailments of GOSTR pancreatitis neyasnoї etіologії EWS dozvolyaє viyaviti abo viklyuchiti etіologіyu biliary pancreatitis (holedoholіtіaz, patologіya OBD) vnutrіshnoprotokovі mutsіnprodutsіruyuschіe neoplasia puhlini, kіstoznі utvorennya, viznachiti їh topografіchne roztashuvannya at neobhіdnostі spend tonkogolkovoї punktsіyu patologіchnogo utvorennya.

KhPG. It is indicated for the development of choledocholithiasis, stenosis, strictures, cysts, polyps, diverticulums and other pathologies of the posterior zhazhny duct, as well as the cephalic pancreatic duct (DPP). The sensitivity of the method in the presence of choledocholithiasis is 70-80%, the specificity is 80-100%. In connection with frequent acceleration (development of ERCP-associated pancreatitis is not safe), ERCP for diagnostic purposes is guilty of stagnation for more hard indications. For cychic purposes, it is more often than not to use non-invasive methods of dosage (EUS, magnetic resonance cholangiopancreatography (MRCP)).

Esophagogastroduodenoscopy. Allowing the development of the disease of the shlunk and the twelve-fingered intestine, which is a possible cause of the pathology of the gallants, for example, abdominal pain syndrome, diagnostics of the pathology of OBD.

For the purpose of the motor-evacuation function of the ZhM and the tone of the sphincter apparatus of the zhivchnyh shlyakhiv are shown:

1. Dynamic ultrasound cholecystography based on a well-known methodology, as a result of a vimiryuvanna volume of ZhP before and after a 10-hour interval with a duration of 1.5 years.

2. Dinamіchna gepatobіlіostsіntіgrafіya of otsіnkoyu zhelchesekretornoy funktsії pechіnki per hour maximum nakopichennya radіofarmpreparatіv in pechіntsі (Tmax pechіnki) per hour of radiopharmaceutical napіvvivedennya pechіnki (T? Pechіnki) depositing funktsії gallbladder after hour maximum nakopichennya radіofarmpreparatіv in gallbladder (Tmax LQ), the motor-evakuatornoї Functions of ZHP for an hour napivvedennya radiopharmaceutical from ZHP (T½ ZHP) and latency hour zhovchogіnnogo sіdanku.

Oglyadovaya X-ray analysis of a transverse emptying allows for the presence of X-ray exposure / negativity of calculi that appear during ultrasound examination in ZhP or zhovchny paths.

Multispiral CT of transverse emptying with intravenous contrasts is one of the most accurate methods of visualization (sensitivity - 56-90%, specificity - 85-90%), I can get better during CT scan. It is shown to clarify the nature of the urinary tract і її in relation to the otchuyuyu organs with the mark of vyklyuchennya pukhlinny process.

Magnetic resonance imaging and MRCPG allow the direct imaging of the bilar system, the ducts of the pedunculated zone, and the contrast-free angiography and cholecystocholangiography. Indicated in the presence of multiple calculi in the duct system, directly from their localization, in case of adolescence on the internal ducts of fluff. MRCP allows the appearance of irregularly ringing DPP (with an adolescence for autoimmune pancreatitis), strictures in the choledochus and internal ducts.

Duodenal duodenal probe, zokrem, stage non chromatic duodenal probe (EHDZ) with graphical reconstruction of zhovchivіlennya, rozrahunkov stimulated the year-long debut of zootchі and іvchenya іnіvіnіy іnіyu debіt іvchіnkovo. Yes, there is a possibility, within the framework of one advanced diagnosis, of the breakdown of the processes of labor, vision, motility of the bilious tract, as well as the initiation of types of cholesecretory liver disease. Biochemistry permits the establishment of a warehouse, diagnostics of the stages of chronic bilious deficiencies. After that, you can also verify the lithogenic fire and activate the processes of igniting and litigation.

The value of the psychovegetative camp of the patients:

a) pre-development of the autonomic nervous system (autonomic tone, autonomic reactivity and autonomic disease);

b) the development of psychological status (reactive anxiety, special anxiety and depression).

4. Likuvannya

conservatively

The tactics of managing ailments in housing and communal services is guilty of but differentiated from the fallow stage of illness (Scheme 1).

Tactics for managing ailments at the BS stage

1. We are sick with more severe BS in the form of important hyperechogenic particles, when there are fewer symptoms of the disease, it is necessary to carry out therapy. If BS is spared, it is necessary to give medication to the drug before the therapy.

2. We are sick with BS in the form of non-uniform zhivchі with the appearance of clots and HL; conservative therapy is necessary because of clinical symptoms.

3. The basic drug for all forms of BS is ursodeoxycholic acid (UDCA), which is prescribed in a dose of 10-15 mg / kg mass once a day for 1-3 msec. from the performance of the control ultrasound schoomisyatsya. In the middle of the gallantry term lykuvannya zazvychay not change 3 m / s. In case of BS, which is against the hypotonia of the HP and / or the hypertonicity of the sphinkter Oddi, to the UDCA it is necessary to add mebeverine hydrochloride (Duspatalin®) 200 mg 2 r. / Dobu. Recommended course for the drug Duspatalin® is not less than 30 days. In case of impaired psycho-motility and / or vegetative erythrocyte - 2-mercaptobenzimidazole at a dose of 10 mg 3 r. / Sut until the sludge again.

4. In the complex of conservative therapy, the inclusion of organopreparations is shown - Enterosan and hepatosan, t. K. Vony nadayut the frequency of the heart, injected into the synthesis of cholesterol in the hepatocyte and its absorption in the intestine. In the complex with UDCA preparations, it normalizes the colossal stability of the cheeks and reduces the transport of cholesterol to the wall of the ZhP, the stench on the old ryvnya infuses a good infusion on the catabolism of cholesterol.

Tactics for managing ailments at the stage of cholecystolithiasis

Due to the widespread introduction into the clinical practice of laparoscopic cholecystectomy, conservative methods of treatment in housing and communal services have gone to a different plan, they have not lost their meaning.

Oral litholytic therapy

From the home population of ailing housing and communal services, 20-30% can be used as a basis for political therapy. For oral litholytic therapy, gum acid preparations are used. Oh litolithic effect of kindness. Chenodeoxycholic acid (CDCA) replaces the deficiency of gum acids in the gum, inducing the synthesis of cholesterol in the liver, setting the cellulose in the cholesterol, in the endocytic bag, changing the lytogenic power. UDCA decreases the intensity of cholesterol for the reduction of its absorption in the intestine, suppressing the synthesis in the liver and the decrease in secretion in the gut. In addition, the UDCK is in charge of the precipitation of CS (more nucleation hour) and the adoption of rare crystals.

1. Indication of pre-litolithic therapy

1. Клінічні:

• the visibility of the female rings or the ridkisn_ attack;
• the visibility of the collapse of the passage of the gum ducts;
• when a sick person is ill on cholecystectomy with the help of stabilization, the process of stonework.

2. Ultrasound:

• the size of a single calculus is not more than 1 cm;
• homogeneous, low-choogenic structure of the stone;
• rounded or oval in shape to calculus;
• the surface of the calculus, close to the rivnoi, or at the viglyad "mulberry berry"; viklyuchayutsya stones from the polygonal surface;
• weak (filthy pomytna) acoustic tin behind the calculus;
• the diameter of the acoustical tin is less than the diameter of the calculus;
• more often the calculus falls when the body changes;
• a lot of dry calculi with a total volume of less than 1/4 of the volume of fatty acids;
• the coefficient of consumption (CO) of ZhP is not less than 30-50%.

Take an additional dose of UDCA (10-15 mg / kg) once in the evening before bedtime (during the period of maximum functional calmness of the gastrointestinal tract). HDCA is priznachayut in an additional dose of 12-15 mg / kg. It is permissible to take CDCA and UDCA at 7-10 mg / kg / day for skin.

2. Prototype indications prior to literary therapy:

• pigment stones;
• cholesterol stones with high content of calcium salts (according to CT, the coefficient of weakening according to the Hounsfield scale (HOC)> 70 od.);
• stones more than 10 mm in diameter;
• kamenі, scho zapovnyuut more 1/4 obsyagu ZhP;
• reduced SFZhP (KO<30%);
• parts of the gum disease in the anamnesis (after taking into account the available contraindications, since in some of the ailments on the litholithic therapy, the frequency of gum rings changes, or they smell like a call);
• obesity prevails.

The effectiveness of lithological therapy lies in the form of reticence in sickness, triviality of sickness and in wide fringes: in case of early emergence of housing and communal services, and lower in the case of ailments, we have triviality of stony in sound In case of sparing SFZhP, the effectiveness of the therapy is in proportion to that with a decrease in SFZhP.

The effectiveness of the treatment is controlled for the additional ultrasound, as it is necessary to conduct through the skin 3 ms. Visibility of positive dynamics in 6 ms. therapies є provided for її hunts and feeds about the operative treatment.

With the use of CDCA, in about 10% of ailments, diarrhea and an increase in the activity of aminotransferases are indicated, as well as a decrease in the dose of the drug due to the onset of advancing to therapeutic. In connection with cym during litholytic therapy, biochemical monitoring of the level of activity of skin aminotransferases is required 3 m / s. With the intake of UDCA, the secondary effects are even worse (not more than 2-5%). In vipadki, resistant to therapy, the dose of UDCA is increased to 15-20 mg / kg / day.

Vagitnist not є contraindicated before the designation of the UDCA.

Before the signs of literary therapy, the drug is guilty of informing the sick about those who:

• lіkuvannya trivale і road;
• On the other hand, there may be some grudges, as well as the need for prompt treatment;
• Successful resolution does not lead to a relapse of stone recovery.

Extracorporeal shock-khvilova lithotripsy

Extracorporeal shock-khvilova lithotripsy (EUHL) - the ruining of stones behind the help of percussion khvil, induced by the generator. According to the preliminaries, 20% of the housing and communal services ailments may be shown for the EUHL. The method in Danish hour is victorious as a preparatory stage for a given oral literary therapy. As a result of crushed stones, the surface is increased, and the course of literary therapy is fast.

1. Shown before EUHL:

• functional ZhP (KO for a zhovchoginny snidank not less than 50%);
• prohidnі zhovchnі way;
• X-ray transparent stones or concretions with weak acoustic tint, concretions with tighter acoustic tint, loosely spreading out from the surface;
• sumarny obsyag of stones not more than 1/2 of the volume of fatty acids;
• the size of stones is not more than 3 cm and not less than 1 cm;
• the visibility of the empty ones in the course of the shock;
• visibility of coagulopathy.

2. Prototype indications before EUHL:

• the manifestation of coagulopathy;
• anticoagulant therapy was performed;
• the manifestation of empty lighting in the course of shock damage.

With the correct selection of ailments on lithotripsy, fragmentation of calculi can be reached in 90-95% of cases. Lithotripsy is successful, as long as it is possible to get rid of calculi up to a diameter of ≤5 mm. In a number of vipadkiv BS pereshkojaє yakisnoy EUHL. In some cases, there is an early 3-month course of litolithic therapy with the help of EUHL. With lithotripsy of great stones, it is necessary to reach the top of the force of the shock. To prevent the acceleration of the crushing of the great stones (the block of the galls was set up in numerical fragments, the zhovchna ring, the increase in the activity of transaminases, the host of cholecystitis), the complete revision of the therapy, the most great overflowed stones to the required diameter. Pislya EUHL prescribes preparations of gum acids in the same doses as in oral litholytic therapy.

3. EUHL storage:

• zhovchna ring;
• gostry cholecystitis;
• hypertransamіnazemіya;
• block of post-pectoral gum ducts;
• micro- and macrohematuria.

Contact for the distribution of gum stones

In case of contact litholysis, the solution is introduced without the need for a second place in the gastrointestinal tract, or in the gut ducts under radiological or ultrasound control. In clinical practice, a number of drugs are used for the preparation: methyl tertiary butyl ether (MTBE), isopropyl acetate, ethyl propionate, acetylcysteine, monooctanoin and in. Shown before contact litholysis is frozen are X-ray-negative (cholesterol) gum stones, the percentage of which does not change 100 od. H. Vidnosnі evidence - anomalies in the development of ZhP, which complicate the procedure, large stones or concretions, which occupy a significant part of the ZhP. Absolute counter-indications: inclusions of ZhP, vagіtnіst.

Tactics for treating ailments with asymptomatic stone carriage

Decision about operatively treating ailments with asymptomatic stone carriage was observed individually in the skin, with indications and evidence of conservative methods of treatment.

A memory slid, which is a form of prevention tactics for treating ailments with asymptomatic stone formation and more early cholecystectomy, taking into account the preventive maintenance of housing and communal services, including Ch. Cancer ZhP.

Tactics for managing ailments at the stage of chronic cholecystitis

antibacterial therapy

Antibacterial therapy is indicated in case of acute chronic cholecystitis, as it is clinically characterized, as a rule, in cases of pain in the right debris, more frequent attacks of mothballs, increased temperature of the disease, leukocyte contours, extra sludge, especially health

• Napivsynthetic penicilin: amoxicilin, amoxicilin + clavulanic acid vseredin 500 mg 2 r. / Dobu, 7-10 days 1.
• Macrolide: clarithromicin * 500 mg 2 r. / I will do it all in the middle, 7-10 days 1.
• Cephalosporin: cefazolin, cefotaxime, 1.0 g of skin 12 years IM, 7 days 1.
• Fluorohinoloni: ciprofloxacin 250 mg 4 r. / I will do it all in the middle, 7 days; pefloxacin 400 mg 2 r. / I'll add all the middle, 7 days1.
• Nitrofurani: furazolidone 50 mg 4 r. / Dobu; nitroxoline 50 mg 4 r. / I'll add all the middle, 10 days 2.

Pain relief

• Drotaverin 2% razchin 2-4 ml in viglyad monotherapy or in some cases with other antispasmodics or
• metamizole sodium 5 ml i.v. dropwise, 3-5 days.

For the purpose of correcting the patient's indications, the shift to selective myotropic conditions for the correction of biliary dysfunction and the sphincter device (mebeverine hydrochloride and in.). The triviality of therapy should not be less than 1 ms.

Correction of biliary dysfunctions

(To hypertonus of the sphinkter Oddi)

With the help of normalization to the tone of the sphinkter Odd, we reduce the sign of selective myotropic spasmolytics.

• Mebeverin vseredin 200 mg, 1 capsule 2 r. / Dobu, from 14 days to 1 ms. and more (the triviality of therapy is not limited) or
• hymecromone vseredin 200 mg 1 tablet 3 r. / day, 14 days abo
• domperidone vseredin 10 mg 1 tablet 3 r. / day, 14 days.

Enzyme therapy replacement

To become stagnant in chronic biliary pancreatitis, with a stretch of which superfluous disease occurs.

For a substitute enzyme therapy in the given hour, it is recommended to use microcapsulated preparations in an enzymatic shell. Dose the drug to lie down at the step of exocrine deficiency:

• in case of normal exocrine func- / add;
• in case of exocrine deficiency - Creon 10,000, 2 capsules 5 p. / add;
• in case of exocrine deficiencies - Creon 25,000, 1 capsule 6 p. / day

Home course lіkuvannya - 6 ms. and more.

The stagnation of tablet preparations and those more enzyme inputs, for the replacement of gum acids, is not indicated for carrying out enzyme replacement therapy.

surgical treatment

Borrowing a provincial place in the lіkuvannі ailments of housing and communal services and is a vision of housing at the same time from stones or only stones from housing. You can see the onset of the operative engagement at the close of the cyclists:

• traditional (standard, vidkrita) cholecystectomy;
• surgery with small access (Videolaparoscopic and "open-cut laparoscopic" cholecystectomy with mini-access);
• cholecystolitotomy.

Shown before surgical treatment

cholecystolithiasis:

• from the appearance of great and / or other concrements of the ZhP, which occupy more than 1/3 of the volume of ZhM;
• directly from the growth of calculi, which is opposed to the frequent attacks of the gum rings.

In addition:

• with a decrease in SFZhP (KO for zhovchoginny<30%);
• from connecting ZhP;
• s choledocholithiasis.

accelerations:

• cholecystitis і / abo cholangitis;
• Mіrіtsi syndrome;
• development of dropsy abo empієmi ZhP;
• penetration, perforation, fistulas;
• bilious pancreatitis.

choledocholithiasis

Nutrition about the tactics of the management of patients with choledocholithiasis and is shown before the operative treatment to be treated spirally with a surgeon. At the same time, there are many endoscopic methods.

The group, with the help of an operating risik, will store ailments with important fellow ailments, such as:

• ischemic ailment of the heart is of the 3-4 functional class, there is a lack of legacy;
• the importance of the decompensated form of diabetes mellitus;
• uncorrected deterioration of blood loss.

Prevention of postcholecystectomy syndrome

The frequency of development of the postcholecystectomy syndrome is 40-50% when the operative gain is reached. For the prevention of the given syndrome, the following recommendations are given:

• promptly entrusted with the drive of the housing and communal services of the viconuvati until the development of the acceleration;
• the complex treatment of ailments in the preoperative period is not negligible due to the development of clinical symptoms due to the development of functional and organ pathology of the bilious tract and correction of damage. For the improvement of the accuracy of diagnostics, it is wider than that of the EUS and EHDZ;
• we have a problem with cholesterol cholesterol colitis, it is shown that it is carried out for a stretch of 1 ms. before operation і 1 mіs. for the operation of the course of therapy with UDCA drugs in a standard dose of 10-15 mg / kg body weight, dal - in the fallowness of the evanescent stage of bilious deficiency;
• in the presence of hypercholesterolemia, as well as in the presence of cholecystolithiasis with gallbladder cholesterosis, it is shown to be carried out for 1 ms. before operation і 1 mіs. for operating courses of therapy with UDCA drugs at a dose of 15 mg / kg mass;
• for the prevention of recurrent choledocholithiasis in case of dysfunction of the sphincter Oddi (hypertonicity), it is shown that selective myotropic spasmolytics (mebeverine hydrochloride in a standard dose) last for 1-2 months;
• early rehabilitation of ailments with cholecystectomy in the minds of a special gastroenterological sanatorium;
• dispensary for ailments of cholecystectomy with a stretch of 1 fate.

rehabilitation

• Before the regime of food and children with fat, gostrich and greased strains;
• Retention of mineral waters with low mineralization and re-cultivation of hydrocarbonate-anioniv.

Sanatorium and health resort lykuvannya

1 Stagnate in the presence of a swollen zagostrennya: pain syndrome, changes in blood analyzes and in the presence of a moon-graphic picture, to indicate the ignition process in the ZhP (trisharova wall ZhP, dragging and dropping by 3 mm).
2 Stagnate with a slight interruption of the disease: pain syndrome of non-rotations, with an echography - a slight increase in the gastrointestinal tract, a clinical analysis of blood - without changes.
* May podovzhuvati QT interval due to the threat of paroxysmal lingual tachycardia.

VALUE. Zhovchnokam'yana hvoroba (HCS) - zahvoryuvannya scho harakterizuєtsya utvorennyam konkrementіv in zhovchnomu mіhurі (holetsistolіtіaz) zagalom zhovchnomu prototsі (holedoholіtіaz), yak Mauger protіkati of symptoms zhovchnoї (bіlіarnoї, pechіnkovoї) kolіki in vіdpovіd on skorominuschu obstruktsіyu STONE mіhura abo zagalnogo zhovchnogo duct, which is supervised by a spasm of smooth mucous membranes, intraductal hypertension.

In ecologically developed regions, housing and communal services develop in 10-15% of the population. From 21 to 30 years of housing estates, 3-4% of settlements, from 41 to 50 years - 5%, older than 60 years - up to 20%, older than 70 years - up to 30%. The overwhelming pidloga is a woman's (2-5: 1), I want to see the tendency of growing sickness among the choloviks.

Ethiology and pathogenesis

Factories, scho to produce gum stones (before cholesterol) to be approved: vik (older than the patient, tim vishche ymovirnist of housing and communal services); genetic and ethnical features; the nature of the food is overwhelmingly fatty and rich in cholesterol, food fat, zukru, malt; vaginism (bagatorazovy curtains in anamnesis); obesity; hunger; ailment of the club intestine - syndrome of a short intestine, Crohn's ailment and іn.; zasosuvannya deyakykh lykarskih zasobіv - clofibrate, estrogenіv, somatostatin and іn.

The main reason for the stone production is the destruction of the physical and chemical warehouse and the stagnation of women, the infection of women’s nobles. In the womb, cholesterol does not differ in water, in order to preserve the homogeneity of the cholesterol to accumulate in the concentration of cholesterol, gum acids and lysolycetin. The basis of the establishment of calculi is the strengthening of the secretion of cholesterol.

Classification of gum stones

For localization:

in zhovchny mіkhury

in the gum duct

in pechinkovy ducts

For a number of stones:

alone

many

Behind the warehouse:

• cholesterol - to replace in the main cholesterol, may be round or oval, sharuvat structure, diameter from 4-5 to 12-15 mm; typical localization - zhovchny mikhur

  pigment (bilirubin) are characterized by small sizes, many are very popular; zhorstki, tendency, absolutely homogeneous, the yak grows out in the rump michury, as well as in the rump ducts

  zmіshanі (appear the most often) - often many, most popular forms; this warehouse includes cholesterol, bilirubin, gum acids, bile, glucoprotein, food salts, microelements.

Classification of housing and communal services for key interruption:

latent form (stone bearing);

primary chronic cholecystitis;

bile ring;

chronic recurrent cholecystitis.

clinika

Often, housing and communal services are asymptomatic (latent recession is observed in 60-80% of individuals with stones in a rumpy bone and in 10-20% of individuals with stones in a backbone prototype), and concretions appear vaguely when carried out. Diagnosis of housing and communal services should be given on the basis of clinical donations (the most common variant in 75% of patients is gallbladder) and ultrasound results.

The main key manifestation of housing and communal services is a bile ring (chill out in the form of a quick stone obstruction of the Mikhura duct).

Vona is characterized by hospitable visceral pains from localization in the epigastric or right-sided region, before the pain occurs only in the left-sided region, precardial region or the lower half

In 50% of patients, pain is radiated to the back and to the right scapula, interscapular region, to the right shoulder, and to the left half of the tulub.

The triviality of the zhivnoy coli becomes from 15 minutes to 5-6 hours. More triviality more than 5-6 hours is to be guilty of the suspicion of the doctor, so it’s getting worse, the first for all the hospitable cholecystitis.

Pain syndrome supravodzhutsya pіdіvisheno pіdlivіstyu, grimace of pain on the face and immobilisation - on botsі from the legs to the abdomen. In some cases, there is a nuisance and blues. The diagnosis of pain can be overwhelmed by the implantation of fatty food, spicy food, alcohol, physical nutrition, emotional experience. Bil is tied with the overstretching of the stink of the mikhur in the form of an increase in the internal vise and spastic speed of the sphinkter Odd or the ducts of the mikhur. In case of zhivnoy ring, there is a slight increase in temperature, protest and hyperthermia (38 ° C) in the presence of symptoms of intoxication (asthenovegetative syndrome, dryness and deposition of language) Yavlennya zhovtyanitsi invite you to familiarize yourself with the obstructions of zhovchividnyh nobles.

When taking an anamnesis, it is necessary to especially relieve a sick person with pain in the abdomen in the past, but when the housing and communal services are progressing, it is necessary to relapse, to develop a protracted nature, the pain is intense.

Possible nonspecific symptoms, for example, severity in the right side of the area, flatulence, dyspeptic manifestations.

You can see the symptom of a muscular disease, alleviating the pain with palpation in the area of ​​the right ridge and bitty edges of the valley along the right costal dus, as well as the symptom of Murphy (a mimic eye of the pain on the back of the palm of the hand) The admission of a gross cholecystitis is characterized by the appearance of specific ignition symptoms from the side of the rump

Mikhura (marvelous article "chronic no kam'yaniy cholecystitis").

DIAGNOSTICS

Relative anamnesis and physical condition (typical signs of a chewing ring, symptoms of a burnt chewing mikhur).

Carrying out ultrasonic scanning in the capacity of the per-shot method, or even the last time, allows the visualization of gum stones. However, it’s not possible to find the stones with the available methods; enlargement of zhovchny ducts, including internal furnaces, according to ultrasound; changing liver samples (zagalny bilirubin, ALT, ACT, gamma-glutamyltranspeptidase, LF, the last to move in case of diagnosed cholestasis due to obstruction of the zeal duct).

The laboratory dosage is necessary for the detection of the stiff obstruction of the youthful nobles or the admission of the State Cholecystitute.

One of the important diagnostics goals is to respect the interconnection of the uneasy consumption of housing and communal services (asymptomatic stone carriage, incapacitated gallbladder) and the availability of possible acceleration (hospitable cholecystosis, hospitable coldness).

Laboratory dosage

For the uninterrupted relocation of housing and communal services, changes in laboratory indicators are not typical.

With the development of the state of cholecystitis and concomitant cholangitis, leukocytosis (11-15x10 9 / l) may develop (11-15x10 9 / l), increase in the activity of syvate aminotransferases, cholestase enzymes - LF, y-glutamyltransmitters / l -7 mg%).

OBOV'SKOVI LABORATORY DOSLIJENNYA

Zalnoklіnіchnі Doslіdzhennya: Clinical analysis of blood. Leukocytosis due to the destruction of the leukocyte formula is not characteristic of the ruminant colic. Call wine winyk if you are admitted to the state cholecystitis or cholangitis; reticulocyti;

coprogram;

zagalny analysis of the slaughter;

blood plasma glucose

Indicators of lipid metabolism: high blood cholesterol, lipoprotein of low grade, lipoprotein of even low grade.

Functional tests of the liver (it is associated with choledocholithiasis and obstruction of the gallbladder): Act; ALT; y-glutamyltranspeptidase; prothrombinovy ​​index; puddle phosphatase; bilirubin: zagalny, straight, albumin of blood;

Ferments of slurry plant: blood amilase, sech amilase.

Dodatkov_ laboratory dosl_djennya

Marker for viruses in hepatitis:

HB s Ag (surface antigen of hepatitis B virus); anti-HB 3 (anti-hepatitis B nuclear antigen); anti-HCV (anti-hepatitis C virus).

instrumental doslіgennya

In case of a clinically primed suspicion on the housing and communal services in the first place, it is necessary to carry out an ultrasonic inspection.

Housing for Dіagnoz pіdtverdzhuyut dopomoga komp'yuternoї tomografії (zhovchnogo mіhura, zhovchnih duct pechіnki, pіdshlunkovoї zalozi) of kіlkіsnim viznachennyam koefіtsієnta Weak zhovchnih kamenіv by Haunsfіlda (Method dozvolyaє pobіchno to judge about the warehouse on konkrementіv їh schіlnostі) magnіtno-rezonansnoї holangіopankreatografії (dozvolyaє viyaviti invisible during ultrasonic examination of stones in young galls, sensitivity 92%, specificity 97%), ERHPG (highly informative method of implantation of postoperative ducts upon admission to the stone of the deepest glandular ducts and for those who have included

OBOV'SKOVI INSTRUMENTAL DOSLIJENNA

Ultrasonic inspection of organs in the empty wood is the best available method with the highest indicators of sensitivity and specificity for the detection of gum stones: for stones in the gum mixture і ducts of the mikhura sensitivity of ultrasonic scan become 89%, specificity - 97%; for stones in a zagalny zhovchny prototype - sensitivity is less than 50%, specificity is 95%. Necessary purpose of straightening shocks: widening of internal and post-pectoral gum ducts; calculi in the education of the zhivka michur and zhovchivi nobles; a sign of a hospitable cholecystitis in the viglyadі of the stink of the ruminant michur more than 4 mm and the appearance of the “sub-contour” of the stink of the rump mikhur.

Oglyadovaya radiography of the area of ​​the ruminant: the sensitivity of the method for detecting gum calculi is to become less than 20% when looking at them often x-ray negatives.

FEGDS: carry out assessments of the slunk and twelve-fingered intestine, look around the great papilla of the twelve-fingered intestine when adolescent for choledocholithiasis.

Differential diagnosis

The yellow ring is necessary to differentiate from the offensive 5 stanіv.

Bіlіarny sludge: in some sposterіgayut a type of a classic picture of a zhovchny colika. Characteristic is the appearance of a zhovchny siege in a zhovchny mіkhury at ultrasonic inspection.

Functional incapacitation of a young woman's microscope and young people’s paths: when it’s hard not to know a stone, there are signs of a deterioration in the fast-feeling health of a young woman’s (hypo- or hyperfunctions), a spasmodic Pathology stravohod: esophagitis, esophagospasm, gryzhi stravochidny opening diaphragms. Characteristics of pain in the epigastric disease and behind the sternum in common with typical symptoms in FEGDS or radiological pre-diagnosis of the upper intestinal tract.

Vibrant ailments of the slunk and twelve-fingered intestines. Characterized by bіl in epіgastralіy dіlyantsі, inodі irradіyuє in the back and the change in time, taking antacids and anti-secretory drugs. It is necessary to carry out FEGDS.

Zakvoryuvan pidshlunkovoi zolozi: grievous and chronic pancreatitis, pseudocyst, pukhlin. Typical bile in epigastric dileantsi, radiating to the back, provoked by the intake of the stomach and often superfluous blues. Determination of diagnostics of additional help in detecting advanced activity in the blood of amylase and lipase, as well as typical changes based on the results of methods of interim diagnostics. Slid vrahovuvati, housing and communal services and bіlіarniy sludge can produce up to the development of severe pancreatitis.

Poisoning of the stove: a dull bile is characteristic of the right sided region, radiating to the back and to the right shoulder blade. Become more persistent (which is atypical for pain syndrome in case of crumbling) and support for malignant liver diseases during palpation. The determination of the diagnosis additionally assists in the presence of liver enzymes in the blood, markers in the hepatitis B and visualization of the diagnosis.

Illness of the intestine: the syndrome of the gutted intestine, fiery urazheni (especially when the hepatic viginus of the intestine is found in the pathological process). Pain syndrome is often associated with motor impairment. It often changes due to defecation or gas supply. Vidreznitsi functional changes from organic allow colonoscopy or rigoscopy.

Zahvoryuvan legends and pleurisy. Characteristic manifest pleurisy, often associated with a cough and badness. It is necessary to carry out, X-ray dosage breast cancer.

Pathology of skeletal muscle. Moist bile in the right upper quadrant of the abdomen, tied with rukhs or to accept the singing position. Palpation of the ribs can be painful; the pain can be relieved with the pressure of the mucous membranes of the anterior cervical wall.

LIKUVANNYA

Shown before hospitalization

At the surgical hospital:

recurrent malignant colitis;

hospitality and chronic cholecystitis and accelerated disease;

gostry biliarny pancreatitis.

At the gastroenterological hospital:

chronic calculous cholecystitis - for detailed preparation and preparation for operative or conservative treatment;

zagostrennya housing and communal services and the state of cholecystectomy (chronic bilious pancreatitis, dysfunction of the sphinkter Oddi).

The triviality of stationary treatment: chronic calculous cholecystitis - 8-10 days, chronic bilious pancreatitis (fallen as a serious illness) - 21-28 days.

Lіkuvannya includes in itself dіntotherapy, stasis of lykarsky labor, methods of distant lithotripsy and operatively.

non-drug treatment

dietotherapy: at all stages, I recommend 4-6 times of food intake for the inclusion of products, which will support the appearance of the food, the secretion of the slurry and the slurry. Viklyuyuyut smoked meats, refractory fats, savory seasonings. The reason for this is to include a large number of rosebuds with additional viscosities, not only normalizing intestinal peristalsis, but changing the lithogenicity of the gut. With a chewing ring, you need hunger for 2-3 days.

Lykarska therapy

Oral litholytic therapy is a single effective conservative method for treating gallstones. For the development of stones, use gum acid preparations: ursodeoxycholic acid (Ursofalk, Ursosanu) and chenodeoxycholic acid.

Ursodeoxycholic acid helps to moisten cholesterol in the intestine and when cholesterol is transferred from stone to gum.

Chenodeoxycholic acid is the synthesis of cholesterol in the liver and also in the reduction of cholesterol stones. Treatment with gum acid preparations should be performed and monitored on an outpatient basis.

Zhorstki criteria for the ailment of those who are averse to this method are available for an even smaller group of patients from the unrelenting interruption of ill health - for about 15% of housing and communal services. Visoka partiality is also intertwined with the zasosuvannya method. The most favorable conditions for the result of oral lithotripsy are:

in the early stages of becoming ill;

in case of an unresolved housing and communal services leak , childish epizodes of the cheekbone, in terms of pain syndrome;

with the presence of pure cholesterol stones ("flush" with 3 oral cholecystography);

if there is evidence of noncalcified stones in the microscopy (the weakening factor at CT is less than 70 Hounsfield units);

■ when the size of the stones is not more than 15 mm (when using shock-and-hammer lithotripsy - up to 30 mm), the best results are spared when the diameter of the stones is up to 5 mm; with lonely stones, it should take no more than 1 \ 3 of the gum mikhur;

■ while preserving the fast-feeling function of the grub. Prototype indications prior to conservative therapy of housing and communal services:

Housing and communal services have been arranged, including the hospitality and chronic cholecystitis, so how the sick are shown sanitation of female nobles and cholecystectomy.

Introductions of zhovchny mikhur.

Parts of an epizodi of a zhovnoy colic.

Viability.

Virazhene obesity.

Vіdkrita vyrazka slunk or two-fingered intestine.

Patients suffering from liver disease - hospitality and chronic hepatitis, liver cirrhosis.

Chronic diarrhea.

Rustic carcinoma.

The revelation in the chewing ministry of pigment and known cholesterol stones.

Stone with a diameter of 15 mm.

The number of stones, which occupy more than 50% of the education of the zhovchny mikhur.

We have a problem with chenodeoxycholic acid at a dose of 15 mg / kg / add or ursodeoxycholic acid at a dose of 10 mg / kg / add a single dose of the entire dose in the evening before bedtime, drinking a large amount of water. The most effective and often recommended treatment regimen - one-hour intake of chenodeoxycholic acid at a dose of 7-8 mg / kg and ursodeoxycholic acid at a dose of 7-8 mg / kg once a day. The triviality of the drug rises from 6 to 24 months with uninterrupted drug intake. Independently of the effectiveness of the litholytic therapy, there will be a weakening of the incidence of pain syndrome and a decrease in the development of the state of cholecystitis. Lіkuvannya to carry out before control of the stone mill for the data of ultrasonic scanning of skin 3-6 months. Repeat the process of calculating the ultrasonic stones in 1-3 ms.

It is recommended to use ursodeoxycholic acid for 3 months at a dose of 250 mg / day for the development of stones. The rate of positive dynamics behind the ultrasound data after 6 months of taking the drug will indicate the ineffectiveness of oral lytolithic therapy and in the case of the need for correction.

Antibacterial therapy. It is indicated for patients with gross cholecystitis and cholangitis (div. Statue "chronic cholecystitis without kam'yaniy").

surgical treatment

In case of asymptomatic interruption of housing and communal services, as well as in case of single episodes of female colicity and infrequent painful episodes of most cases, the most effective tactics are clinical. If it is evident, it is possible to perform oral lithotripsy in cich vipads.

Indicated before surgical treatment for cholecystolithiasis:

■ the appearance of great and other concrements in the grunt of the world, which occupy more "/ 3rd volume;

perebіg zhvoryuvannya with frequent attacks zhovchnykh rings, right in the form of concrements;

inclusions of zhovchny mikhur;

Housing and communal services, accelerated by cholecystitis and / or cholangitis;

onset of choledocholithiasis;

Housing and communal services, accelerated by the development of the Mіrіtsi syndrome;

Housing and communal services , slowed down by dropsy, the temperament of the zhovchny mikhur; Housing and communal services, accelerated by perforation, penetration, fistulas;

Housing and communal services, accelerated by bilar pancreatitis;

Housing and communal services

zhovnoy ducts.

Methods of surgical treatment: laparoscopic or vidcritic cholecystectomy, endoscopic papillosphincterotomy (indicated for choledocholithiasis), extracorporeal shock-hviliova lithotripsy.

Cholecystectomy. With an asymptomatic stonemasonry, there is no visualization of the risk of surgery, the development of symptoms is reduced. However ryadі vipadkіv Venue of laparoskopіchnoї holetsistektomії vvazhayut vipravdanim navіt at vіdsutnostі klіnіchnih proyavіv (indications to holetsistektomії at bezsimptomnomu kamenenosіystvo Je kaltsifіkovanimi "porcelain" zhovchny mіhur; kamenі rozmіrom bіlshe 3 cm; maybutne trivale perebuvannya in regіonі of vіdsutnіstyu kvalіfіkovanoї medichnoї dopomoga; sickle klіtinna anemіya ; may be sick with organ transplantation).

When the symptoms of housing and communal services are evident, especially often, cholecystectomy is indicated. As a result, the laparoscopic option in the maximum possible number of cases (less incidence of pain syndrome, quicker terms of transfer to the hospital, less traumaticity, greater short result of cosmetic surgery)

Nutrition about the term of cholecystectomy in patients with gross cholecystitis becomes discouraged until the end of the hour. Traditions are used to quickly add (after 6-8 times) quickly, to carry out conservative therapy with the associated antibiotics for the suppression of hostile heat. However, otrimanі danі, wіddіng about those thаt thе early (stretching out decіlkoh days іn thе ear іn thе ear) laparoscopic cholecystectomy is superseded by the same frequency of slowing down, rather than allowing the rapid rate of death.

Absolute contraindications before laparoscopic manipulations are practically non-existent. Until recently, there is a diagnosis of cholecystitis in cases of triviality more than 48 hours, peritonitis, cholangitis, obstructive fever, internal and chronic fever fistula, liver cirrhosis, coagulopathy, malaise

Shock-khvilova lithotripsy stays tighter, so as to achieve a wide range of indications, a number of indications and acceleration. Extracorporeal shock-khvilovu lithotripsy stasis in the onset of the fall. The appearance in the grinder is not more than three stones with a diameter of less than 30 mm. Detection of concrements, "fusing" during oral cholecystography (characteristic signs of cholesterol stones). Funktsionuyu chevy michur for the data of oral cholecystography. The speed of zhovchny mikhura is 50% based on scintigraphy data.

Slid vrahovuvati, without a supplemental treatment of ursodeoxycholic acid, the frequency of recurrences of stonework reaches 50%. Moreover, the method is not capable of developing a crustacean crayfish into a maybutny one.

Endoscopic papillosphincterotomy is indicated for choledocholithiasis.

FORECAST

The efficiency of the conservative policy is to end up being high: with the correct selection of ailments, more stones are spared in 18-24 months in 60-70% of patients, however, there are no recurrences of sickness.

literature

CHRONICLE-free cholecystitis (CBC)

VALUE. Chronic stoneless cholecystitis is a chronically recurrent stinging of the stink of a mothball, which is superfluous to the deterioration of its motor-tonic function.

ICD 10 Loan cholecystitis Up to 81

Ethiology and pathogenesis

I will play a role in the development of chronic cholecystitis of the state of infection, the infectious disease bearer to become hematogenous and lymphogenous paths, before it is visceral, so that from two to twenty intestines. Sponsor the development of toxic and allergic inflammation in the grout. You can also use pancreatic enzymes to use pancreatic enzymes, so you can use it as a vise in the ampulla of the zhazhnoy zhovnoy duct. Such forms of cholecystitis are carried to enzymatic.

The role of viral hepatitis in the pathogenesis of chronic inflammation of the bilious system is significant.

In the middle and senior age, a negative role is played to control blood circulation in the stage of the female mink, which develops on the smallest atherosclerotic lesions of the arteries of the ruminant, and in case of systemic lesions of the vessels.

Actually, the role in the pathogenesis of chronic cholecystitis is the deterioration of the motor-evacuation function of the moth muscle (dyskinesia), which may be the development of the chronic ignition process, as well as the inherited one (second dyskinesia)

KLASIFIKATSIYA

Functional damage (discines)

Flame (cholecystitis, cholangitis)

Obminni (housing and communal services)

Anomalies of development (visibility of the microorganism, separation, constrictions, diverticulums, aplasia and hypoplasia of the internal and external ducts)

after

KLINIKA

Clinical manifestations of dyskinesia of the moth-mongering and chronic cholecystitis of the malignant and not plausible symptoms and specific rice. It is classic to get into the "symptom of the right pidreber'ya" (N. A. Skuya) - more symptoms in the upper right half of the abdomen, if the stench is not a symptom of the disease.

It is highly appreciated that the nature of scarg in chronic cholecystitis is a type of dyskinesia. It is classic to get involved in the fact that in case of hyperkinetic dyskinesia, it is meant to endure intense pain in the right side of the ribs, and how to think about it.

For hypokinetic dyskinesia is characterized by the appearance of severity, development in the area of ​​the right sidebar, swelling, dyspeptic syndrome. If you want the character of the scarg can be varied.

The destruction of the motor-evacuation function of the young people - tse neuzgodzhene, overwhelmingly, for lack of speedy grub mishura and sphinkteriv 0ddі, Lyutkens, Mirіzzi .

Classification of functional connections in the biliary tract:

Primary dyskinesias, which zoom in on damage to the gut and / or pancreatic secretion in the intestine in two to twenty digits when there is an absence of organ transcripts

Dysfunction of the michur

Dysfunction of the sphinkter Oddi

Secondary dyskinesia of the bilious tract, to share with the organic wines of the ruminant and the sphinkter Oddi

The reasons for the destruction of the gum mikhur:

pervinny

Disruption of the function of smooth mucous membranes of the gallbladder (change in muscle mass or sensitivity of receptors)

Discoordination of gallbladder and duct functions

second

Hormonal disorders - vaginism, premenstrual syndrome, somatostatin treatment

Pislyoperatsіynі stan - resection of the shlunka, application of anastomoses, vagotomy

Systemic discomfort - diabetes, liver cirrhosis, gluten enteropathy, myotonia

Availability of fired stones in ZhP

About AGALNI classic dyskinesias are seen in the "Roman minds." Rome-3 in case of biliary pain: localized in the epigastric region and in the right upper quadrant of the abdomen; awakening at night. Seeing endocrine (spastic) dyskinesia, which appears in women in the premenstrual period on the basis of hyperfolliclemia. At the same time, injecting vitality, statics, professional, decline, social, social factors, design features, as well as injecting specific pathologies into the functional activity of young people. Great influx of supportive pathology. So among ailments of diabetics, obesity tends to decrease the speedy function of the chewing mishur. In ailments, hypermotor discinesia of young people form on the twisting ailment of the KDP.

The well-known terminology of discinesis is often classified as evidenced by the presence of morphological changes in the background of the mothball. Diskіnezіya Mauger Buti Parvin (funktsіonalnoї) without morfologіchnih for Change in stіntsі zhovchnogo mіhura, tobto viklikanoї zmіnami funktsіonalnogo will CNS, hormonal torn down, vіstseralnimi reflexes at zahvoryuvannyah organіv cherevnoї porozhnini i vtorinnoї, pov'yazanoї of morfologіchnimi zmіnami in stіntsі zhovchnogo mіhura in rezultatі glow protsesіv in niy (cholecystitis).

Due to the nature of the deterioration of the motor-evacuation function of the chewing machine, the hypothesis is developed into a hyperkinematic form of dyskinesia.

DIAGNOSTICS

Diagnostic tests for diseases of the bilious tract

screening

• Duodenal probe (motility, concentration, tone of the sphincter Oddi, inflammation - mucus, leukocytes, gum cells, chromatic probes - gum acids, cholesterol)

  The value of bilirubin, puddle phosphatase, ALT, AST, amylase and blood lipase for an hour or less than 6 years after the end of the pain attack

clarify

Ultrasound scan with the assessment of the function of the chef and sphinkter Oddi

ERHPG with sphinkter Oddi manometer

Hepatobіlіstіntіgraphіya z 99m Tc

Medication test (with cholecystokinin, morphine - prostigminovy ​​provocation test)

Computer tomography

Nuclear Magnetic Resonance

Diagnosis of chronic cholecystitis The main diagnostic criterion for chronic cholecystitis is ultrasound of cholocation of the rump mink. About the stage of turnover of the ignition process, reduce the thickness and thickness of the glass-gall micher (in the norm, the thickness of the wall does not change 3 mm).

Strengthening the echostructure of the zhovchny mikhur ( deformation), deformation of the growth, as a sign of organic changes in the stage of zhovchny michur, characteristic of chronic cholecystitis; and the growth of the stinka of the zhovka michur is more than 3 mm, the sub-contour grows, like a sharpening of the chronic ignition process in the new one.

1. The size of the wall of the grout is more than 4 mm in individuals without liver pathology, nirok, heart defect, with a lot of flexibility, and when the wall is more than 5 mm, it is more durable.

2. Evidence of the sonographic symptom of Murphy;

3. The increase in the size of the gum microscope is 5 cm lower than the upper limit for the patients of the given test.

4. Evidence of those from the stinks of the chewing mikhur;

5. Determination of paravesical ehonegactivity (ridina), which is more typical for a hospitable process.

True cholecystitis is infrequent. Under the mask of cholecystitis, there are endless discines of female nobles, which, obviously, more. To make a diagnosis of chronic cholecystitis, it is necessary to provide a thorough analysis of anamnestic, clinical and echographic data.

For diagnostics of the type of dyskinesis, it is worthwhile to use the methods of fractional chromatic duodenal probe (FCDZ) with methylene blue and ultrasound echolocation with choleretic breakdown.

Criteria for diagnostics of dysfunction of the ruminant michur, summarized by the hipofunction of the mucous membranes of the ruminant michur:

1. The presence of trivial, not infrequently persistent pains in the right sidebar, not infrequently in one or more of these signs:

blues nudity

ruinous style

2. Hypomotor dyskinesia of the ruminant

Criteria for diagnostics of the dysfunction of the moth maker, supplemented by the discoordination of the function of the moth moth:

1. The incidence of pains of a biliary type (pain in the right side of the border or an epigastric triviality not less than 20 minutes.) According to one or more of these signs:

irradiation in the back or the right shoulder blade

Winning a letter to the receptionist and in a new year

blues nudity

2. Disruption of the function of the chewing mikhur

3. The visibility of structural changes in the biological system

Apply key diagnoses

Increased aggravation of chronic cholecystitis with swelling of the motor-evacuation function of the chewing mikhur by the type of hypokinesia

LIKUVANNYA

In the therapy of the XX century with the use of antibacterial drugs, antibacterial drugs, diseases of the disease, diseases of the disease, in the therapy of dysfunctions of the mothballs and the diseases of the diseases in the diseases of the diseases

Indicated before the appointment of gum preparations:

Choleretics (allochol, cholenzyme, hofetol, tsikvalone, nikodin, hepatofalk planta and іn.) In addition, with enzymes for the correction of intestinal dislocations, they indicate in the phase of remission and in the phase of fading, acute, chronic cold. Therapeutic effect of choleretic dressings with tim, how stinks, stimulating the secretion of the gums, stimulating the struma on the gum moves, which also changes the intensity of the ignition process and increasing the increase in visceral movement

Choleretics with the use of zhovch acids (deholin, libil, cholenzyme, dehydrocholic acid, etc.)

Cholekinetics (magnesium sulfate, sorbitol, xylitol, olimetin, cholosas ) to docilely stasis in case of malnutrition , for cholecystectomy.

The prototype is shown before the recognition of the :

in case of a swelling zagostrennі ignition process in the zhovchny mihury and zhovchny ducts. Zhovchogіnnі will be recognized in 3-5 days after the fire is bought.

with chronic hepatitis (hepatocytes are unnatural).

With hyperkinetic dyskinesia of the beetle michur.

with chronic pancreatitis in the stage of aggravation.

Stan pislya cholecystectomy

With the appearance of uncommon appearances at the right side of the edge, the manifestation of congestive appearances in the post-pecunian zhovchnyh nobles, such as zhovchoginniy with a plentiful supply of mineral waters. If necessary, it is possible to identify nikodin, tsikvalon, as zhovchoginnykh, which may be antibacterial.

Options for antibacterial therapy for acute chronic cholecystitis:

1. ciprofloxacin- 500 - 750 mg - 2 times a day, 7-10 days.

2. Preparations of the tetracycline series: doxycycline(Vibramicin-Poland) in therapeutic doses.

3. erithromicine 200 - 400 mg X 4 times a day, 7-14 days or so rovamycin 1.5 MO x 2 times a day per os.

Correction of therapy is possible depending on the clinical effect and the results of the pre-duodenal one.

On the way from zagostrennya to antibacterial drugs, as soon as the course of antibiotic therapy is given a course of antibiotic drugs: allochol, 2 tablets. 3 - 4 times a day drink food, Hofitol 2 cap. 3 times for additional drugs, which prevent choleresis and cholecinesis.

Adequate therapy of chronic cholecystitis and the correction of motor-evacuation breakdowns of the grub give a singular opportunity to overcome the development of gum disease.

at hypokinetic discinesia of the beetle michur it is recommended to vikoristovuvati tyubazhi with mineral water, sorbitol, prokinetics (Motilium 10 mg 3-4 times a day), choleretics, cholecystokinetics, physiological physical culture, active roach regime, swimming. Hofetol is used as a preparation for hypoxinetic discinesia of the ruminant, which is 3.5-5 times higher and more rapid in the health of the ruminant.

With hyperkemia shows the sign of myotropic spasmolytics (dycetel, duspatalin, meteospasmil, no-shpa, golidor and in.), holinolytics (platifilin, buscopan 1-2-drops 3-4 times for dobu). vypravdanny at the reception of hypermotor disks of ZhVP from the IBS.

literature

Practical hepatology \ p_d. Ed. N.A. Mukhina - Moscow, 2004. - 294 p.

Older than P.S. Zhovchnokam'yana ailment and cholecystitis // Clinical perspectives of gastroenterology, hepatology. - 2005. - No. 1- З 16-24.

Peter R., McNelli "Secrets of Gastroenterology", Moscow, 2004.

Licheva V.G "Fundamentals of clinical gastroenterology", Moscow, N-Novgorod, 2005