Chronic cholecystitis: diagnosis

Laboratory and instrumental data

Fractional duodenal sounding

Fractional duodenal sounding (PDD) has the following advantages over conventional duodenal sounding:

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

Before inserting the probe, a pharyngeal smear should be taken for bacteriological examination, then the patient should rinse the oral cavity with a disinfectant solution to reduce the possibility of drifting microflora from the oral cavity into bile portions. The duodenal probe is injected into the 12-colon early in the morning on an empty stomach. It is more preferable to use the two-channel probe of NA Skuya for separate extraction of gastric and duodenal contents. One channel of the probe is located in the stomach, the other in the duodenum. Gastric juice should be continuously removed by a syringe or vacuum unit, as when gastric acid enters the 12-colon, the bile becomes cloudy. In addition, hydrochloric acid stimulates pancreatic secretion and bile secretion through the release of secretin secretion and cholecystokinin-pancreosimin.

In the absence of a dual-channel probe, a single-channel duodenal probe should be used.

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

There are 5 phases of fractional duodenal sounding.

1 - choledochus phase - begins after the olive probe 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 clear light yellow bile is allocated from the common bile duct (d. Choledochus) as a result of irritation of the duodenal ulcer of the olive probe.

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

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

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

After the end of the bile secretion into the 12 duodenum through the duodenal probe slowly, within 5-7 minutes, a warm 33 ° solution of magnesium sulfate-30 ml or 5% -50 ml heated to 37 ° C is introduced.

In response to the introduction of the stimulus, the sphincter of Oddy reflexively closes and is closed during the entire second phase of probing.

2 phase - the closed sphincter of Oddi (the phase of the latent period of bile secretion) - reflects the time from the administration of the cholecystokinetic solution to the appearance of a secretion of the gall. At this time, bile is not excreted. This phase characterizes the cholestatic pressure in the biliary tract, the readiness of the gallbladder to emptying and its tone.

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

If the bile appeared before 3 minutes, this indicates a hypotension of the sphincter of Oddi. The increase in the time of the closed sphincter of Oddi is greater than 6 minutes indicating an increase in its tone or a mechanical obstruction to the outflow of bile. To resolve the issue of the nature of the changes, 10 ml of warm (warmed to 37 ° C) 1% solution of novocaine can be introduced through the probe. The appearance of a light yellow bile after this testifies to the spasm of the sphincter of Oddi (novocaine relieves spasm). If after injection of novocaine bile is not released within 15 minutes, the patient can give under the tongue 1/2 of the nitroglycerin tablets and, in the absence of the effect, re-enter through the probe into the 12-colon of the cholekinetic agent (20 ml of vegetable oil or 50 ml of 40% glucose solution, xylitol). If bile does not appear and after this, the position of the probe in the duodenum should be checked radiographically, and if the probe is positioned correctly, stenosis in the region d can be assumed. Choledochus.

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

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

This phase reflects the state of these ducts. Increasing the time of 3 phases more than 7 minutes indicates an increase in the tone of the sphincter of Lutkens (it is located at the junction of the cervix of the gallbladder in the cystic duct) or hypotension of the gallbladder.

About the hypotension of the gallbladder can only speak after comparing the data of III and IV stages.

Bile 1, 2 and 3 phases constitute the classical portion of A normal (non-fractional) duodenal sounding.

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

The 4th phase begins with the discovery of the sphincter of Lutkens and the appearance of dark olive concentrated bile and ends at the moment of stopping the secretion of this bile.

Isolation of the gall bladder at first is very intense (4 ml per 1 minute), then gradually decreases.

Normally, the time for emptying the gallbladder is 20-30 minutes, during this time, an average of 30-60 ml of dark olive gallbladder is released (in chromatic probing, the bile is colored blue-green).

Intermittent excretion of cystic bile indicates the dissyncism of the sphincters of Lutkens and Oddi. The lengthening of the time for the release of cystic bile (more than 30 minutes) and an increase in the amount of more than 60-85 ml indicates a hypotension of the gallbladder. If the duration of 4 phases is less than 20 minutes and less than 30 ml of bile is released, this indicates hypertonic dyskinesia of the gallbladder.

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

Bile-C is advisable to collect for 1 hour or more, studying the dynamics of its secretion, and try to get the residual vesicle bile without repeated administration of the gallbladder stimulus.

The repeated contraction of the gallbladder normally occurs 2-3 hours after the introduction of the stimulus. Unfortunately, in practice duodenal sounding is completed 10-15 minutes after the appearance of hepatic bile.

Many suggest to allocate 6 phase - a phase of a residual cystic bile. As indicated above, 2-3 hours after the introduction of the stimulus, a repeated contraction of the gallbladder occurs.

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

Some researchers suggest not to wait 2-3 hours, and soon after receiving the hepatic bile (after 15-20 minutes) to introduce an irritant to be sure of complete emptying of the gallbladder. The receipt of additional amounts of vesicle (residual) bile in this time interval indicates an incomplete emptying of the gallbladder with its first contraction and, consequently, its hypotension.

For a more detailed study of the function of the sphincter apparatus of the bile ducts, it is advisable to study biliary excretion graphically, while the volume of bile obtained is expressed in ml, during bile extraction - in min.

Propose to determine a number of indicators of biliary excretion:

• the rate of excretion of bile from the bladder (reflects the efficiency of the ejection of bile by the bladder) is calculated by the formula:

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

• the index of evacuation - the index of the motor function of the gallbladder - is determined by the formula:

IE = H / Vostat * 100%. IE-evacuation index; H is the rate of excretion of bile from the bladder; Vostat - residual volume of cystic bile in ml. Normally, the evacuation index is about 30%;

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

VEV = V portion B from bile for 1 hour in ml / 60 min, where EVP is an effective release of hepatic bile. Normally, the EWL is about 1-1.5 ml / min;

• the index of secretory liver pressure is calculated by the formula:

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

Fractional duodenal sounding can be made chromatic. For this, on the eve of duodenal sounding at 2100 2 hours after the last meal, the patient takes inward 0.2 g of methylene blue in a gelatin capsule. The next morning at 9.00 (i.e., 12 hours after dye ingestion), fractional sounding is carried out. Methylene blue, sucked in the intestines, with blood flow enters the liver and is restored in it, turns into a colorless leuco compound. Then, after getting into the gallbladder, the discolored methylene blue oxidizes, turns into a chromogen and stains the bladder bile in a blue-green color. This allows you to confidently distinguish between gall bladder and other phases of bile that retain the usual color.

The bile obtained by duodenal probing is examined biochemically, microscopically, bacterioscopically, its physical properties and flora sensitivity to antibiotics.

To investigate bile it is necessary immediately after its reception, as contained in it bile acids quickly destroy uniform elements. To deliver bile to the laboratory should be in a warm form (tubes with bile are placed in a jar with warm water), so that it is easier to detect lamblias with microscopy (in cold bile they lose their motor activity).

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

1. The presence of a large number of leukocytes, especially the detection of their accumulations. Finally, the question of the diagnostic value of the detection of leukocytes of bile, as a sign of the inflammatory process, has not been resolved. In any portion of the duodenal contents, leukocytes can get from the mucous membrane of the oral cavity, stomach, duodenum. Often, leukocytes are taken by leukocytoids - cells of the cylindrical epithelium of the duodenum, transformed under the influence of magnesium sulfate into large round cells resembling leukocytes. In addition, it should be borne in mind that leukocytes are quickly digested by bile, which of course reduces their diagnostic significance.

In connection with this, it is now believed that the detection of leukocytes in portion B is a sign of the inflammatory process only if the following conditions exist:

• if the number of leukocytes is really large. To identify leukocytes, the Romanovsky-Giemsa coloration should be used, as well as a cytochemical study of the content in peroxidase cells. Leukocytes give a positive response to myeloperoxvdazu, leukocytoids - no;
• if clusters of leukocytes and cells of the cylindrical epithelium are found in flaky mucus (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.

Detection of leukocytoid is not given a diagnostic value. To detect leukocytes and other cells in the bile, you should view at least 15-20 preparations before the microscope.

2. Identification of a visual examination of bile expressed by its 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 cells in the bile of the cylindrical epithelium. It is known that three types of cylindrical epithelium can be found in bile: fine epithelium of intrahepatic bile ducts - with cholangitis (in "C" portion); elongated epithelium of the common bile duct with its inflammation (portion "A"); wide epithelium of the gallbladder with cholecystitis.

Chronic cholecystitis is characterized by the detection of a large number of cells of the cylindrical epithelium in the gall bladder in a large number of cells. Cells of the cylindrical epithelium are found not only in the form of separate cells, but also in the form of clusters (strata) of 25-35 cells.

4. Decreased pH of the gallbladder. The bile bile has a pH of 6.5-7.5. In inflammatory diseases of the bile-excreting system, the reaction becomes acidic. According to the researchers at an exacerbation of chronic cholecystitis the pH of the gall bladder can be 4.0-5.5.
5. The appearance of crystals of cholesterol and calcium bilirubinate. Chronic cholecystitis is characterized by the appearance of crystals of cholesterol and calcium bilirubinate. The detection of a large number of them indicates the destabilization of the colloidal structure of bile (discrinia). With the appearance of conglomerates of these crystals and mucus, we can speak about the lithogenic properties of bile, the formation of microliths, and the peculiar transformation of cholecystitis to calcale calcite. Along with microlites, sand is often found - small, recognizable only under a microscope, grains of various sizes and colors (colorless, refracting light, brown), which are located in the flakes of mucus.
6. Reduction of the relative density of the gall bladder. Normally, the relative density of the gall bladder is 0.016-1.035 kg / l. With a pronounced exacerbation of chronic cholecystitis, the relative density of the gall bladder decreases as a result of the dilution of its inflammatory exudate.
7. Change 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, enzymes.

When the chronic cholecystitis worsens, the biochemical composition of bile changes:

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

Lipoprotein macromolecular complex formed in the liver complex compound, which includes the main components of bile: bile acids, phospholipids, cholesterol, bilirubin, protein, grouped around the lipoprotein nuclei with the formation of a macromolecular complex. The lipoprotein complex provides colloidal stability of bile and its intake from the liver into the intestine. Bile phospholipids form micelles with cholesterol, and bile acids stabilize them and transfer cholesterol into a soluble form;

• the content of fibrinogen and the products of its metabolism in the cystic bile increases sharply;
• proteinocholia is observed - increased secretion of whey proteins (mainly albumins) in bile, while reducing the secretion of immunoglobulin A.

8. Increase in the content of gall bladder peroxide lipids.

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

9. Bacteriological study of bile. The purpose of bacteriological study of bile is the detection of bacterial flora and the determination of its sensitivity to antibacterial agents. The study is of diagnostic significance if the number of bacteria exceeds 100,000 in 1 ml of bile.

Ultrasound examination of the gallbladder

Ultrasound (ultrasound) is currently the leading method for diagnosing biliary system diseases. The resolving power of modern ultrasonic devices is 0.1 mm.

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

Ultrasound is performed in the position of the patient lying on his back with a delay in breathing in the deep inspiratory phase, and, if necessary, also on his left side and standing.

Normally, the gallbladder looks like a clearly contoured echo-negative formation of 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. Usually the thickness of the wall of the gallbladder does not exceed 2 mm. The outer and inner contours of the wall of the bladder are clear and even. According to research, the density of the wall of the bladder increases with age. After 60 years in the muscle layer and mucous membrane of the bladder, the connective tissue gradually develops, the wall of the bladder is sclerosed and compacted. Therefore, the density of the gallbladder wall should be evaluated taking into account the age of the patient.

Echographic signs of chronic cholecystitis:

• thickening of the gallbladder wall more than 2 mm. It should be noted that diffuse thickening of the gallbladder wall can also be observed with hypoalbuminemia in liver cirrhosis;
• sealing the wall of the gallbladder, especially with thickening. Local compaction (increased echogenicity) of the gallbladder wall occurs with cholesterosis. Cholesterol gallbladder - deposition of cholesterol esters in the wall of the bladder with a violation of its motor function. It also occurs in full women after 35 years old. With cholesterosis, the walls of the gallbladder on the echogram are thickened and have a transverse striation;
• Unevenness and deformation of the bubble contour;
• decrease or absence of movement of the gallbladder during breathing;
• inhomogeneity of the contents, "bile sediment" ("parietal inhomogeneity of the cavity of the gallbladder"). This precipitate consists of crystals of cholesterol, calcium bilirubin, thick bile, microliths;
• painfulness when the sensor of the device is pressed onto the area of the gallbladder projection (a positive ultrasonic Murphy symptom);
• increase or decrease in the size of the gallbladder;
• deformation of the bladder by adhesions, restriction of its displacement when the position of the body changes (pericholecystitis);
• infiltration of the liver cavernous tissue, which is manifested by increased echogenicity of the hepatic parenchyma around the gallbladder with an uneven contour of the border along the periphery of this echogenic area;
• a decrease in the dilatability of the gallbladder due to the development of inflammatory-sclerotic changes in its wall. To identify this feature, a dehydrocholic acid sample is used. 2-3 hours after ingestion of dehydrocholic acid (10 mg / kg body weight) with choleretic effect, the volume of the gallbladder is measured by the sum of the cylinders, the lumen of the choledoch is measured, 0.5-0.8 ml of 0.1% solution of atropine sulfate is injected subcutaneously and the measurements are repeated 50 -70 minutes. If the lumen of the choledocha has increased or has remained the same size, and the gallbladder volume has increased by less than 30%, chronic cholecystitis is diagnosed.

Echography also makes it possible to diagnose dyskinesia of the gallbladder.

X-ray examination of the gallbladder

X-ray methods of examination of the gallbladder (review radiography, oral cholecystography, intravenous cholecystocholangiography) are used primarily for the diagnosis of stones in the bile duct and violations of the motor function of the gallbladder.

The role of X-ray methods of investigation in the diagnosis of chronic non-calculous cholecystitis is low. The most significant radiographic signs of chronic non-calculous cholecystitis are:

• a violation of the concentration ability and motor function of the bladder (a sharp slowdown in the emptying of the gallbladder);
• deformation of the gallbladder (uneven contours due to pericholecystitis).

Radioisotope investigation of bile ducts

The most optimal is hepatobiliary scinthesia using 95m Tc. The method makes it possible to detect primarily violations of the motor function of the gallbladder. Chronic non-calculous cholecystitis manifests itself on scintigrams with the following symptoms:

• persistent impairment of filling and emptying of the gallbladder;
• increase or decrease in its size;
• sealing the bed of the gallbladder.

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. With a marked exacerbation of chronic cholecystitis in the projection of the gallbladder, a local temperature increase of 0.3-2 ° C is noted. In this case, on the thermograph (thermal imager) the zone of the gallbladder looks bright (the more active the inflammatory process, the brighter the glow).

Peripheral blood analysis

Changes in the analysis of peripheral blood depend on the severity of the inflammatory process, concomitant diseases and complications. In the period of exacerbation of chronic cholecystitis the following changes can be observed: moderate leukocytosis; shift of the leukocyte formula to the left with an increase in the number of stab wedges; increased ESR.

Blood chemistry

With exacerbation of chronic cholecystitis in the blood, the content of sialic acids, seromucoid, fibrin, and _2- globulins increases, and in the case of a recurrent course, an increase in the level of y-globulins is possible.

Immunological blood tests

With a prolonged course of chronic cholecystitis with frequent, persistent relapses, moderately pronounced 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 of class A.

Degrees of gravity

The mild form is characterized by the following manifestations:

• exacerbations rare (1-2 times a year) and short (not more than 2-3 weeks);
• pains are not intensive, localized in the gallbladder area, last 10-30 minutes, pass most often independently;
• the function of the liver is not disrupted;
• there are no complications.

Medium severity:

• exacerbations are frequent (5-6 times a year), are protracted;
• pain resistant, prolonged, have a characteristic irradiation, are stopped by antispasmodics, analgesics;
• functional liver samples may be impaired;
• complications are possible on the part of the digestive system, a few, not very pronounced.

The severe form has the following characteristic features:

• exacerbations are frequent (1-2 times a month and more often) and prolonged;
• pain intense, last long, stop only repeatedly injected analgesics and antispasmodics;
• complications from the system of the digestive system develop often, are expressed distinctly. As a rule, a severe, complicated form is accompanied by the formation of stones in the gallbladder.

[1], [2], [3], [4], [5]