Chronic cholecystitis - Diagnosis

Laboratory and instrumental data

Fractional duodenal intubation

Fractional duodenal intubation (FDS) has the following advantages over conventional duodenal intubation:

• allows you to get a clearer idea of the functional state of the gallbladder and bile ducts;
• allows to diagnose the type of gallbladder dyskinesia.

Before inserting the tube, a pharyngeal swab should be taken for bacteriological examination, then the patient should rinse the oral cavity with a disinfectant solution to reduce the possibility of introducing microflora from the oral cavity into portions of bile. The duodenal tube is inserted into the duodenum in the morning on an empty stomach. It is more preferable to use a two-channel tube of N. A. Skuya for separate extraction of gastric and duodenal contents. One channel of the tube is located in the stomach, the other - in the duodenum. Gastric juice should be continuously extracted with a syringe or vacuum unit, since when hydrochloric acid of gastric juice enters the duodenum, bile becomes cloudy. In addition, hydrochloric acid stimulates pancreatic secretion and bile excretion due to the release of secretin and cholecystokinin-pancreozymin hormones.

If a two-channel probe is not available, a single-channel duodenal probe should be used.

Collection of bile from duodenal contents is carried out in numbered test tubes every 5 minutes.

There are 5 phases of fractional duodenal sounding.

1 - choledochochus phase - begins after the probe olive is located in the duodenum (angle of the descending and lower horizontal part). During this period, the sphincter of Oddi is in a relaxed state and a portion of transparent light yellow bile is released from the common bile duct (d. choledochus) as a result of irritation of the duodenum by the probe olive.

The time during which bile is secreted and its volume are taken into account.

Phase 1 reflects the basal secretion of bile (outside digestion) and the partially functional state of the sphincter of Oddi.

Normally, 15-20 ml of bile is secreted within 10-15 minutes (according to some data - within 20-40 minutes).

After the end of the secretion of bile into the duodenum, a warm 33% magnesium sulfate solution heated to 37°C is slowly introduced through the duodenal tube over 5-7 minutes - 30 ml or 5% - 50 ml.

In response to the introduction of the stimulus, the sphincter of Oddi reflexively closes and remains closed throughout the second phase of probing.

Phase 2 - closed sphincter of Oddi (the latent period phase of bile secretion) - reflects the time from the introduction of the cholecystokinetic solution to the appearance of bile-stained secretion. At this time, bile is not secreted. This phase characterizes the cholestatic pressure in the biliary tract, the readiness of the gallbladder to empty and its tone.

Normally, the phase of the closed sphincter of Oddi lasts 3-6 minutes.

If bile appears before 3 minutes, this indicates hypotension of the sphincter of Oddi. An increase in the time of the closed sphincter of Oddi for more than 6 minutes indicates an increase in its tone or a mechanical obstruction of the outflow of bile. To resolve the issue of the nature of the changes, 10 ml of warm (heated to 37 ° C) 1% novocaine solution can be administered through a tube. The appearance of light yellow bile after this indicates a spasm of the sphincter of Oddi (novocaine relieves the spasm). If bile is not released within 15 minutes after the introduction of novocaine, the patient can be given 1/2 a nitroglycerin tablet under the tongue and, if there is no effect, a cholekinetic agent (20 ml of vegetable oil or 50 ml of a 40% glucose solution, xylitol) can be reintroduced through a tube into the duodenum. If bile does not appear after this, the position of the probe in the duodenum should be checked radiologically, and if the probe is positioned correctly, stenosis in the area of the d. choledochus can be assumed.

Phase 3 - A-bile (cystic duct phase) - begins with the opening of the sphincter of Oddi and the appearance of light bile A until the release of dark concentrated bile from the gallbladder.

Normally, this period lasts 3-6 minutes, during which 3-5 ml of light bile is released from the cystic and common bile ducts.

This phase reflects the state of these ducts. An increase in the time of phase 3 over 7 minutes indicates an increase in the tone of the Lutkens sphincter (it is located at the transition of the neck of the gallbladder to the cystic duct) or hypotension of the gallbladder.

Gallbladder hypotension can only be discussed after comparing data from stages III and IV.

Bile of phases 1, 2 and 3 constitutes the classic portion A of conventional (non-fractional) duodenal sounding.

Phase 4 - gallbladder (cystic bile, B-bile phase) - characterizes the relaxation of the Lutkens sphincter and emptying of the gallbladder.

Phase 4 begins with the opening of the Lutkens sphincter and the appearance of dark olive concentrated bile and ends when the secretion of this bile stops.

The secretion of gallbladder bile is initially very intense (4 ml per minute), then gradually decreases.

Normally, the gallbladder takes 20-30 minutes to empty, during which time an average of 30-60 ml of dark olive gallbladder bile is released (with chromatic probing, the bile is colored blue-green).

Intermittent secretion of gallbladder bile indicates dyssynergism of the sphincters of Lutkens and Oddi. An increase in the time of gallbladder bile secretion (more than 30 minutes) and an increase in the amount of more than 60-85 ml indicate gallbladder hypotension. If the duration of phase 4 is less than 20 minutes and less than 30 ml of bile is secreted, this indicates hypertonic dyskinesia of the gallbladder.

Phase 5 - the phase of hepatic bile-C - occurs after the end of the secretion of B-bile. Phase 5 begins with the secretion of golden bile (hepatic). This phase characterizes the exocrine function of the liver. During the first 15 minutes, hepatic bile is secreted intensively (1 ml or more per 1 minute), then its secretion becomes monotonous (0.5-1 ml per 1 minute). Significant secretion of hepatic bile in phase 5, especially in the first 5-10 minutes (>7.5 ml/5 min) indicates the activity of the sphincter of Mirizzi, which is located in the distal part of the hepatic duct and prevents the retrograde movement of bile during contraction of the gallbladder.

Bile - It is advisable to collect it for 1 hour or more, studying the dynamics of its secretion, and try to obtain residual gallbladder bile without re-introducing a gallbladder irritant.

Repeated contraction of the gallbladder normally occurs 2-3 hours after the introduction of the irritant. Unfortunately, in practice, duodenal intubation is completed 10-15 minutes after the appearance of hepatic bile.

Many suggest distinguishing phase 6 - the phase of residual gallbladder bile. As indicated above, 2-3 hours after the introduction of the irritant, the gallbladder contracts again.

Normally, the duration of phase 6 is 5-12 minutes, during which time 10-15 ml of dark olive gallbladder bile is secreted.

Some researchers suggest not to wait 2-3 hours, but to introduce an irritant soon after obtaining liver bile (after 15-20 minutes) to be sure of complete emptying of the gallbladder. Obtaining additional amounts of gallbladder (residual) bile during this period of time indicates incomplete emptying of the gallbladder during its first contraction and, consequently, its hypotension.

For a more detailed study of the function of the sphincter apparatus of the biliary tract, it is advisable to study bile secretion graphically, with the volume of bile obtained expressed in ml, and the time of bile secretion in min.

It is proposed to determine a number of indicators of bile secretion:

• the rate of bile secretion from the bladder (reflects the efficiency of bile release by the bladder) is calculated using the formula:

H=Y/T, where H is the rate of bile secretion from the gallbladder; V is the volume of gallbladder bile (B-portion) in ml; T is the time of bile secretion in min. Normally, the rate of bile secretion is about 2.5 ml/min;

• The evacuation index is an indicator of the motor function of the gallbladder and is determined by the formula:

IE = H/Vостат*100%. IE is the evacuation index; H is the rate of bile secretion from the gallbladder; Vостат is the residual volume of gallbladder bile in ml. Normally, the evacuation index is about 30%;

• the effective release of bile by the liver is determined by the formula:

EVL = V portion of bile C in 1 hour in ml / 60 min, where EVL is the effective release of hepatic bile. Normally, EVL is about 1-1.5 ml/min;

• The secretory pressure index of the liver is calculated using the formula:

The secretory pressure index of the liver = EEJ/H * 100%, where EEJ is the effective release of hepatic bile; H is the rate of secretion of hepatic bile from the gallbladder (effective release of bile by the gallbladder). Normally, the secretory pressure index of the liver is approximately 59-60%.

Fractional duodenal sounding can be made chromatic. For this purpose, the day before duodenal sounding at 2100, 2 hours after the last meal, the patient takes 0.2 g of methylene blue in a gelatin capsule orally. The next morning at 9:00 (i.e. 12 hours after taking the dye), fractional sounding is performed. Methylene blue, having been absorbed in the intestine, enters the liver with the bloodstream and is reduced in it, turning into a colorless leuco compound. Then, having entered the gallbladder, the discolored methylene blue oxidizes, turns into a chromogen and colors the gallbladder bile blue-green. This allows one to confidently distinguish gallbladder bile from other phases of bile that retain their normal color.

The bile obtained during duodenal intubation is examined biochemically, microscopically, and bacterioscopically; its physical properties and the sensitivity of the flora to antibiotics are determined.

Bile should be examined immediately after its collection, since the bile acids it contains quickly destroy formed elements. Bile should be delivered to the laboratory warm (test tubes with bile are placed in a jar with warm water), so that lamblia can be more easily detected under microscopy (in cold bile they lose their motor activity).

Changes in duodenal sounding parameters (portion "B"), characteristic of chronic cholecystitis

1. The presence of a large number of leukocytes, especially the detection of their clusters. The question of the diagnostic value of detecting leukocytes in bile as a sign of an inflammatory process has not been finally resolved. Leukocytes can enter any portion of the duodenal contents from the mucous membrane of the oral cavity, stomach, and duodenum. Leukocytoids, cells of the cylindrical epithelium of the duodenum that have transformed into large round cells resembling leukocytes under the influence of magnesium sulfate, are often mistaken for leukocytes. In addition, it should be taken into account that leukocytes are quickly digested by bile, which, of course, reduces their diagnostic value.

In this regard, it is currently believed that the detection of leukocytes in portion B is a sign of an inflammatory process only if the following conditions are present:

• if the number of leukocytes is really high. To identify leukocytes, one should use Romanovsky-Giemsa staining, and also conduct a cytochemical study of the peroxidase content in the cells. Leukocytes give a positive reaction to myeloperoxidase, leukocytoids do not;
• if accumulations of leukocytes and columnar epithelial cells are found in mucus flakes (mucus protects leukocytes from the digestive action of bile);
• if the detection of leukocytes in bile is accompanied by other clinical and laboratory signs of chronic cholecystitis.

The detection of leukocytoids is not given diagnostic value. To detect leukocytes and other cells in bile, at least 15-20 preparations should be examined under a microscope.

2. Visual examination of bile reveals its pronounced turbidity, flakes and mucus. In a healthy person, all portions of bile are transparent and do not contain pathological impurities.
3. Detection of a large number of columnar epithelial cells in bile. It is known that three types of columnar epithelium can be detected in bile: small epithelium of the intrahepatic bile ducts - in cholangitis (in portion "C"); elongated epithelium of the common bile duct when it is inflamed (portion "A"); broad epithelium of the gallbladder in cholecystitis.

Chronic cholecystitis is characterized by the detection of a large number of columnar epithelial cells (mostly wide) in the gallbladder bile. The columnar epithelial cells are found not only as individual cells, but also in clusters (layers) of 25-35 cells.

4. Decrease in the pH of gallbladder bile. Gallbladder bile normally has a pH of 6.5-7.5. In inflammatory diseases of the biliary system, the reaction becomes acidic. According to researchers, in the case of exacerbation of chronic cholecystitis, the pH of gallbladder bile can be 4.0-5.5.
5. The appearance of cholesterol and calcium bilirubinate crystals. Chronic cholecystitis is characterized by the appearance of cholesterol and calcium bilirubinate crystals. The detection of a large number of them indicates destabilization of the colloidal structure of bile (dyscrinia). When conglomerates of these crystals and mucus appear, one can talk about the lithogenic properties of bile, the formation of microliths and a peculiar transformation of non-calculous cholecystitis into calculous. Together with microliths, "sand" is often found - small grains of various sizes and colors (colorless, refracting light, brown), recognizable only under a microscope, which are located in mucus flakes.
6. Decreased relative density of gallbladder bile. Normally, the relative density of gallbladder bile is 0.016-1.035 kg/l. In severe exacerbation of chronic cholecystitis, a decrease in the relative density of gallbladder bile is observed due to its dilution by inflammatory exudate.
7. Changes in the biochemical composition of bile. Bile is a complex colloidal solution containing cholesterol, bilirubin, phospholipids, bile acids and their salts, minerals, proteins, mucoid substances, and enzymes.

During an exacerbation of chronic cholecystitis, the biochemical composition of bile changes:

• the amount of mucin substances that react with the DPA reagent increases, which significantly increases the activity of the DPA reaction;
• the content of glycoproteins (hexosamines, sialic acids, fucoses) in bile increases by 2-3 times;
• the content of bile acids decreases;
• the cholate-cholesterol ratio (the ratio of the content of bile acids in bile to the level of cholesterol in it) decreases;
• the content of lipoprotein (lipid) complex decreases.

Lipoprotein macromolecular complex is a complex compound formed in the liver, which includes the main components of bile: bile acids, phospholipids, cholesterol, bilirubin, protein, grouped around lipoprotein cores to form a macromolecular complex. The lipoprotein complex ensures colloidal stability of bile and its flow from the liver to the intestine. Bile phospholipids form micelles with cholesterol, and bile acids stabilize them and convert cholesterol into a soluble form;

• the content of fibrinogen and its metabolic products in the gallbladder bile increases sharply;
• proteinocholia is observed - increased secretion of serum proteins (mainly albumins) into bile with a simultaneous decrease in the content of secretory immunoglobulin A.

8. Increased content of lipid peroxides in gallbladder bile.

The increase in the amount of lipid peroxides in bile is a consequence of the sharp activation of free radical oxidation of lipids. The level of lipid peroxides clearly correlates with the severity of the inflammatory process in the gallbladder.

9. Bacteriological examination of bile. The purpose of bacteriological examination of bile is to detect bacterial flora and determine its sensitivity to antibacterial agents. The study has diagnostic value if the number of bacteria exceeds 100,000 in 1 ml of bile.

Ultrasound examination of the gallbladder

Ultrasound examination (US) is currently the leading method for diagnosing diseases of the biliary system. The resolution of modern ultrasound devices is 0.1 mm.

An ultrasound of the gallbladder is performed in the morning on an empty stomach no earlier than 12 hours after the last meal (i.e. after an overnight fast). Patients suffering from concomitant bowel diseases and flatulence are recommended to exclude foods that increase bloating (black bread, peas, beans, sauerkraut, whole milk, grapes, etc.) from their diet 1-2 hours before the examination, and also to prescribe enzyme preparations (digestal or others) 1-2 pills 3 times a day, and activated charcoal before bedtime.

The ultrasound is performed with the patient lying on his back, holding his breath in the deep inhalation phase, and, if necessary, also on his left side and standing.

Normally, the gallbladder looks like a clearly contoured echo-negative formation of a pear-shaped, ovoid or cylindrical shape. The length of the gallbladder varies from 6 to 9.5 cm, and the width (diameter) does not exceed 3-3.5 cm. The wall of the gallbladder looks like a homogeneous thin line of moderately increased echogenicity during ultrasound. Usually, the thickness of the wall of the gallbladder does not exceed 2 mm. The external and internal contours of the bladder wall are clear and even. According to research, the density of the bladder wall increases with age. After 60 years, connective tissue gradually develops in the muscular layer and mucous membrane of the bladder, the bladder wall becomes sclerotic and compacted. Therefore, the density of the gallbladder wall must be assessed taking into account the patient's age.

Echographic signs of chronic cholecystitis:

• thickening of the gallbladder wall by more than 2 mm. It should be noted that diffuse thickening of the gallbladder wall can also be observed with hypoalbuminemia in liver cirrhosis;
• compaction of the gallbladder wall, especially with thickening. Local compaction (increased echogenicity) of the gallbladder wall occurs with cholesterosis. Cholesterosis of the gallbladder is the deposition of cholesterol esters in the wall of the bladder with a violation of its motor function. It also occurs in obese women after 35 years. With cholesterosis, the walls of the gallbladder on the echogram are thickened and have transverse striations;
• unevenness and deformation of the bubble contour;
• decreased or absent movement of the gallbladder during breathing;
• inhomogeneity of the contents, "biliary sediment" ("parietal inhomogeneity of the gallbladder cavity"). This sediment consists of cholesterol crystals, calcium bilirubin, thick bile, microliths;
• pain when pressing the device sensor on the projection area of the gallbladder (positive ultrasound Murphy's symptom);
• enlargement or reduction in the size of the gallbladder;
• deformation of the bladder by adhesions, limitation of its mobility when changing body position (pericholecystitis);
• infiltration of the pericystic liver tissue, which is manifested by an increase in the echogenicity of the liver parenchyma around the gallbladder with an uneven border contour along the periphery of this echogenic area;
• decreased gallbladder distensibility due to the development of inflammatory-sclerotic changes in its wall. To detect this symptom, a test with dehydrocholic acid is used. 2-3 hours after oral administration of dehydrocholic acid (10 mg/kg body weight), which has a choleretic effect, the volume of the gallbladder is measured using the sum of cylinders method, the lumen of the common bile duct is determined, 0.5-0.8 ml of 0.1% atropine sulfate solution is administered subcutaneously and measurements are repeated after 50-70 minutes. If the lumen of the common bile duct has increased or remained the same size, and the volume of the gallbladder has increased by less than 30%, chronic cholecystitis is diagnosed.

Echography also allows diagnosing gallbladder dyskinesia.

X-ray examination of the gallbladder

X-ray methods of examining the gallbladder (survey radiography, oral cholecystography, intravenous cholecystocholangiography) are used primarily to diagnose stones in the bile ducts and disorders of the motor function of the gallbladder.

The role of radiological examination methods in the diagnosis of chronic acalculous cholecystitis is small. The most significant radiological signs of chronic acalculous cholecystitis are:

• impairment of the ability to concentrate and the motor function of the gallbladder (sharp slowdown in emptying the gallbladder);
• deformation of the gallbladder (uneven contours due to pericholecystitis).

Radioisotope study of the biliary tract

The most optimal is hepatobiliary scintigraphy using 95m Tc. The method allows to detect primarily disorders of the gallbladder motor function. Chronic non-calculous cholecystitis is manifested on scintigrams by the following signs:

• persistent disturbances in the rate of filling and emptying of the gallbladder;
• increasing or decreasing its size;
• compaction of the gallbladder bed.

Thermography (thermal imaging)

Thermography is based on the property of the human body to emit infrared rays. The thermograph converts infrared radiation into a visible image. In the case of a pronounced exacerbation of chronic cholecystitis, a local increase in temperature by 0.3-2°C is noted in the projection of the gallbladder. At the same time, on the thermograph (thermal imager), the gallbladder area looks light (the more active the inflammatory process, the brighter the glow).

Peripheral blood analysis

Changes in the peripheral blood analysis depend on the severity of the inflammatory process, concomitant diseases and complications. During an exacerbation of chronic cholecystitis, the following changes may be observed: moderate leukocytosis; a shift in the leukocyte formula to the left with an increase in the number of band neutrophils; an increase in ESR.

Biochemical blood test

_{During an exacerbation of chronic cholecystitis, the content of sialic acids, seromucoid, fibrin, and a2} -globulins in the blood increases, and with a frequently recurring course, the level of gamma-globulins may increase.

Immunological blood tests

With a long course of chronic cholecystitis with frequent, persistent relapses, moderate changes in the immunological status can be observed: a decrease in the number and functional activity of B- and T-lymphocytes, a decrease in the level of immunoglobulins class A.

Severity of the course

The mild form is characterized by the following manifestations:

• exacerbations are rare (1-2 times a year) and short-lived (no more than 2-3 weeks);
• the pain is not intense, localized in the gallbladder area, lasts 10-30 minutes, and usually goes away on its own;
• liver function is not impaired;
• there are no complications.

Moderate severity:

• exacerbations are frequent (5-6 times a year), and are protracted;
• the pain is persistent, long-lasting, has a characteristic irradiation, and is relieved by antispasmodics and analgesics;
• liver function tests may be abnormal;
• Complications from the digestive system are possible, but few in number and not very pronounced.

The severe form has the following characteristic features:

• exacerbations are frequent (1-2 times a month or more) and long-lasting;
• the pain is intense, lasts a long time, and can only be relieved by repeated administration of analgesics and antispasmodics;
• Complications from the digestive system develop frequently and are clearly expressed. As a rule, the severe, complicated form is accompanied by the formation of gallstones.

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