Cholecysto-pancreaticoduodenal syndrome.

The liver, bile ducts, gall bladder, pancreas, and duodenum are closely interconnected anatomically and functionally. Functional disorders or somatic diseases in one of these sections in most cases cause dysfunction in other areas and the development of a symptom complex defined as cholecysto-pancreato-duodenal syndrome, in which the clinical picture of the underlying pathological process that caused its formation prevails.

According to the functional and morphological features, pathologies of this zone of the digestive system can be divided into dysfunctional (spastic, occurring in the form of colic; dyskinesia, giving congestive manifestations; reflux disorders), inflammatory, degenerative and mixed type (inflammatory-degenerative, functional-inflammatory, etc.). A separate column is given to developmental defects and tumors, which can also manifest themselves with this syndrome. According to the clinical course, manifestations of the syndrome can be acute, subacute, chronic, transient.

The pathogenetic basis for the development of the disease is cholestasis - insufficient secretion of bile as a result of its insufficient production by liver cells (intrahepatic) or limited flow into the duodenum (subhepatic).

Intrahepatic cholestasis is manifested by the development of parenchymatous jaundice, skin itching, pain syndrome is absent, splenomegaly is characteristic, the development of the disease is slow, and it is more often observed in women prone to infectious and allergic diseases.

Subhepatic cholestasis develops equally often in both men and women. Clinical manifestations are quite variable, but at the same time serve for differential diagnostics of the process. First of all, it should be noted that cramping pains are characteristic of colic (when localized in the right hypochondrium, they are characteristic of hepatic colic, in the left hypochondrium or encircling - of pancreatic colic, in the right hypochondrium and epigastrium - of duodenal colic, although isolated duodenospasm is extremely rare, more often combined with hepatic colic due to spasm of the sphincter of Oddi).

The transition of colic into organic pathology is accompanied by the formation of constant pain. Jaundice has a mechanical character, and the second main difference from intrahepatic cholestasis is the absence of splenomegaly. Gallstone disease and inflammatory processes are characterized by rapid development of the clinical picture.

Pathology of the duodenum (dyskinesia, peptic ulcer) and the ampulla of Vater (usually strictures) results in a slow development of the clinical picture.

Constant pain by localization also indicates a lesion of a certain area of the cholecysto-pancreato-duodenal zone. In case of pancreatitis, they are encircling or localized in the epigastrium, right hypochondrium in case of local lesion of the head of the gland or in the left hypochondrium in case of lesion of the tail; radiate to the lumbar region, navel, can radiate to the left shoulder, under the shoulder blade, to the heart area, imitating angina pectoris, to the left iliac region. In case of cholecystitis, especially calculous, pain is localized strictly in the right hypochondrium and has a clearer irradiation to the right shoulder, under the shoulder blade, to the neck. Peptic ulcer disease is characterized by: seasonality of exacerbations, night and "hunger" pains, their sharp decrease after eating, soda and other antacids, vomiting, although they can be quite persistent with penetration into the head of the pancreas. With duodenitis, pain in the upper abdomen at the level of the navel, intensifies in the evening, at night, on an empty stomach or 1-2 hours after eating, accompanied by heartburn and sour belching.

Cholecysto-pancreato-duodenal syndrome is accompanied by various but pronounced dyspeptic disorders, which in most cases force the patient to seek medical help: belching, nausea, sometimes vomiting, intolerance to fatty and spicy foods, bloating, constipation combined with diarrhea, or profuse diarrhea, weight loss, irritability, insomnia and other manifestations.

Cholangitis develops when the bile ducts (intrahepatic and extrahepatic) are infected. It is rare in isolation, more often it is combined with cholecystitis (cholecystocholangitis) or hepatitis (hepatocholecystitis): Cholangitis is divided into acute and chronic. Acute cholangitis is accompanied by the clinical picture of cholestasis, but with intense pain; and intoxication syndrome. Jaundice increases after each attack of fever. It is often complicated by liver and subdiaphragmatic abscesses, right-sided pleurisy, pericarditis, peritonitis, pancreatitis, and sepsis. As an outcome of hepatocholangitis, liver dystrophy may develop with an outcome in cirrhosis, accompanied by the formation of portal hypertension and liver failure.

Chronic cholangitis may develop primarily or be the outcome of acute cholangitis. Characteristic are watch-glass-shaped nail deformations and hyperemia of the palms. Dystrophies (fatty, granular, amyloidosis) develop in the liver, which in most cases develop into cirrhosis.

In the latent form of the disease, pain and tenderness during palpation in the right hypochondrium are not expressed or are absent altogether. Weakness, chills, skin itching are periodically disturbing, and there may be a subfebrile temperature.

In the recurrent form of cholangitis, the pain syndrome and local manifestations are weakly expressed, only in the presence of cholelithiasis can sharp pains be noted. Exacerbation of the process is accompanied by fever, skin itching, sometimes jaundice. The liver is enlarged, dense, painful. Sometimes pancreatitis joins. Splenomegaly may occur.

Hepatocholangitis is often included in the group of infectious-allergic diseases, sometimes combined with nonspecific ulcerative colitis (UC), Crohn's disease (terminal ileitis), Riedel's thyroiditis, and vasculitis.

During physical examination, a characteristic complex of additional symptoms for each disease is determined. At present, there are no difficulties in diagnosing cholecysto-pancreato-duodenal syndrome; an accurate topical diagnosis can be made quite quickly during FGS and abdominal ultrasound followed by a complex of additional diagnostic studies (cholangiography, retrograde pancreatocholangiography during FGS, radioisotope examination, etc.).

It is necessary to remember that cholecysto-pancreato-duodenal syndrome can be caused by opisthorchiasis, the incidence of which is growing, and epidemiologists note a high infection rate of all river and lake fish with the Siberian fluke, in some areas even its catching and sale is prohibited. The incidence rate is also growing among tourists, especially when visiting Thailand, France, Italy, who are infected with the molluscan fluke. Opisthorchiasis; occurs with the clinical picture of cholecystitis, cholangitis, pancreatitis. The diagnosis is confirmed by a stool test for helminths. Duodenal intubation is uninformative, since opisthorchiasis larvae are most often detected only during repeated tests.

In all cases of cholecysto-pancreato-duodenal syndrome, especially in the presence of jaundice, it is necessary to be alert for cancer of the pancreato-duodenal zone.

Jaundice is not accompanied by a pronounced pain syndrome, is transient (undulating), has a characteristic greenish tint, and is accompanied by uncontrollable vomiting that does not bring relief. In these cases, magnetic resonance imaging must be performed.

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