Chronic cholecystitis - Symptoms.

Chronic acalculous cholecystitis symptoms are widespread and occur in people of different ages, but still more often in middle-aged people - 40-60 years old.

In people over 75, calculous cholecystitis predominates. Women suffer from both non-calculous and calculous cholecystitis more often than men.

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Subjective symptoms of chronic acalculous cholecystitis

Pain

Pain is the main subjective symptom of the disease. Localization, intensity, duration of pain depend on the type of concomitant biliary dyskinesia, concomitant diseases of the digestive organs, complications of chronic cholecystitis.

Pain in chronic acalculous cholecystitis is usually localized in the right hypochondrium, sometimes in the epigastric region. The appearance or increase of pain is usually associated with a large meal, consumption of fatty, fried, spicy, too cold or too hot food, carbonated drinks, alcohol. Pain is often provoked by intense physical activity or psycho-emotional stress situations. Chronic acalculous cholecystitis is almost always accompanied by dyskinesia of the gallbladder. In the hypotonic variant of dyskinesia, pain in the right side is usually constant, aching, as a rule, not reaching great severity. Sometimes it is not so much the pain that bothers, but the feeling of heaviness in the right hypochondrium.

With concomitant hypertonic dyskinesia of the gallbladder, the pain is paroxysmal, and can be quite intense, which is associated with spastic contraction of the gallbladder muscles. Extremely severe pain (an attack of biliary colic) is usually observed with calculous or "cervical" cholecystitis (predominantly localized in the neck of the gallbladder.

Pain in chronic acalculous cholecystitis radiates to the right shoulder, right shoulder blade, and sometimes to the collarbone. The origin of the pain is associated with spasm of the gallbladder muscles, increased pressure in it (with hypertonic dyskinesia) or stretching of the gallbladder, which is also accompanied by increased intravesical pressure.

When chronic cholecystitis is complicated by pericholecystitis, the pain takes on the character of the so-called somatic pain. It is caused by irritation of the parietal peritoneum, subcutaneous tissue, skin, internalized by sensitive spinal nerves. Pain in pericholecystitis is constant, but intensifies when turning and bending the body, abruptly moving the right hand. It can be more widespread and localized in the liver area. With the development of chronic pancreatitis, the pain can become encircling, radiating to the epigastrium, left hypochondrium, sometimes to the periumbilical region; when complicated by reactive hepatitis, the pain is localized in the area of the entire liver.

Dyspeptic complaints

During the period of exacerbation of chronic cholecystitis, dyspeptic complaints are quite common. Vomiting is observed in 30-50% of patients and can be caused by concomitant gastroduodenitis, pancreatitis. When combined with hypotonic dyskinesia of the gallbladder, vomiting may reduce pain and a feeling of heaviness in the right hypochondrium; with hypertonic dyskinesia, vomiting increases pain. Bile may be found in the vomit. Vomiting, like pain, is provoked by alcohol intake and dietary errors.

During the period of exacerbation of chronic acalculous cholecystitis, patients are often bothered by nausea, a feeling of bitterness in the mouth, bitter belching (especially with concomitant hypotonic dyskinesia of the gallbladder). As a result of the development of secondary gastroduodenitis, gastritis, pancreatitis, enteritis, heartburn, rotten belching, flatulence, loss of appetite, diarrhea appear.

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Skin itching

A symptom reflecting a disturbance in bile secretion and irritation of the skin nerve endings by bile acids. Most typical for cholelithiasis, cholestasis syndrome, but can sometimes be observed in non-calculous cholecystitis due to bile stagnation.

Increased body temperature

It is observed during the period of exacerbation of chronic cholecystitis in 30-40% of patients. It may be accompanied by chills.

Psycho-emotional disorders

Depression, general weakness, rapid fatigue, irritability, emotional lability in chronic acalculous cholecystitis are caused not only by the disease itself, but also by psychotraumatic effects, as well as somatogenic burden in early childhood and adolescence. Psychoemotional disorders, in turn, accompany dysfunction of the biliary tract.

Cardialgia

In 25-50% of patients with chronic acalculous cholecystitis, pain in the heart area of reflex origin is possible during an exacerbation.

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Symptoms of chronic cholecystitis: types

Chronic cholecystitis symptoms of the first group (segmental reflex symptoms) are caused by prolonged irritation of the segmental formations of the autonomic nervous system internalizing the biliary system, and are divided into two subgroups.

1. Viscerocutaneous reflex pain points and zones are characterized by the fact that finger pressure on organ-specific points of the skin causes pain:
   • McKenzie's pain point is located at the intersection of the outer edge of the right rectus abdominis muscle with the right costal arch;
   • Boas's pain point - is localized on the back surface of the chest along the paravertebral line on the right at the level of the X-XI thoracic vertebrae;
   • Zakharyin-Ged's zones of cutaneous hypertension are extensive zones of severe pain and hypersensitivity, spreading in all directions from the Mackenzie and Boas points.
2. Cutaneous-visceral reflex symptoms are characterized by the fact that the impact on certain points or zones causes pain that goes deeper towards the gallbladder:
   • Aliyev's symptom - pressure on the Mackenzie or Boas points causes not only local pain directly under the palpating finger, but also pain that goes deeper towards the gallbladder;
   • Eisenberg's symptom-1 - with a short blow or tapping with the edge of the palm below the angle of the right shoulder blade, the patient, along with local pain, feels a pronounced irradiation deep into the gallbladder area.

Chronic cholecystitis symptoms of the first group are natural and characteristic of exacerbation of chronic cholecystitis. The most pathognomonic are considered to be the symptoms of Mackenzie, Boas, Aliev.

Chronic cholecystitis symptoms of the second group are caused by the spread of irritation of the autonomic nervous system beyond the segmental innervation of the biliary system to the entire right half of the body and right limbs. In this case, a right-sided reactive autonomic syndrome is formed, characterized by the appearance of pain upon palpation of the following points:

• Bergman orbital point (at the upper inner edge of the orbit);
• Jonash's occipital point;
• Mussi-Georgievsky point (between the legs of the right m.sternocleidomastoideus) - right-sided phrenicus symptom;
• Kharitonov's interscapular point (in the middle of the horizontal line drawn through the middle of the inner edge of the right shoulder blade);
• Lapinsky's femoral point (middle of the inner edge of the right thigh);
• point of the right popliteal fossa;
• plantar point (on the dorsum of the right foot).

Pressure on the indicated points is applied with the tip of the index finger.

Chronic cholecystitis symptoms of the second group are observed with frequently recurring course of chronic cholecystitis. The presence of pain simultaneously in several or even more so in all points reflects the severity of the disease.

Chronic cholecystitis symptoms of the third group are revealed with direct or indirect (by tapping) irritation of the gallbladder (irritative symptoms). These include:

• Murphy's symptom - during the patient's exhalation, the doctor carefully places the tips of four semi-bent fingers of the right hand under the right costal arch in the area of the gallbladder, then the patient takes a deep breath, the symptom is considered positive if during exhalation the patient suddenly interrupts it due to the appearance of pain when the fingertips touch the sensitive inflamed gallbladder. In this case, a grimace of pain may appear on the patient's face;
• Kerr's symptom - pain in the right hypochondrium in the gallbladder area during deep palpation;
• Gausmat's symptom - the appearance of pain with a short blow with the edge of the palm below the right costal arch at the height of inhalation);
• Lepene-Vasilenko symptom - the occurrence of pain when applying abrupt blows with the fingertips while inhaling below the right costal arch;
• Ortner-Grekov symptom - the appearance of pain when tapping the right costal arch with the edge of the palm (the pain appears due to the shaking of the inflamed gallbladder);
• Eisenberg-II symptom - in a standing position, the patient rises on his toes and then quickly lowers himself onto his heels; with a positive symptom, pain appears in the right hypochondrium due to shaking of the inflamed gallbladder.

Chronic cholecystitis symptoms of the third group have great diagnostic value, especially in the remission phase, especially since in this phase the symptoms of the first two groups are usually absent.

In chronic acalculous cholecystitis, the gallbladder is not enlarged; in the development of secondary hepatitis, percussion and palpation reveal an enlarged liver (mildly expressed).

Symptoms of chronic cholecystitis involving the solar plexus in the pathological process

With a long course of chronic cholecystitis, the solar plexus may be involved in the pathological process - secondary solar syndrome. The main signs of solar syndrome are:

• pain in the navel area radiating to the back (solargia), sometimes the pain is of a burning nature;
• dyspeptic symptoms (they are difficult to distinguish from the symptoms of dyspepsia due to an exacerbation of chronic cholecystitis itself and concomitant pathology of the stomach);
• palpation of pain points located between the navel and the xiphoid process;
• Pekarsky's symptom - pain when pressing on the xiphoid process.

Some women suffering from chronic cholecystitis may develop premenstrual tension syndrome, which manifests itself in neuropsychic, vegetative-vascular and metabolic-endocrine disorders. Symptoms of premenstrual syndrome appear 2-10 days before menstruation and disappear in the first days after its onset. The development of the syndrome is caused by hormonal imbalance (excessive estrogen levels, insufficient progesterone levels, activation of the renin-angiotensin II-aldosterone system, excess prolactin, impaired secretion of endorphins in the brain). The main clinical manifestations of premenstrual tension syndrome are mood instability (depression, irritability, tearfulness), headaches, puffiness of the face and hands, engorgement and soreness of the mammary glands, numbness of the arms and legs, fluctuations in blood pressure. During this same period, an exacerbation of chronic cholecystitis is observed.

Often, patients with chronic cholecystitis develop cholecystocardial syndrome, which manifests itself as pain in the heart area (usually mild, appearing after drinking alcohol, fatty and fried foods; sometimes constant pain); palpitations or interruptions in the heart area; transient atrioventricular block of the 1st degree; ECG signs of diffuse changes in the myocardium (significant decrease in the amplitude of the T wave in many leads). Reflex, infectious-toxic effects on the heart, metabolic disorders in the myocardium, and dysfunction of the autonomic nervous system are important in the formation of this syndrome.

In people suffering from allergies, an exacerbation of chronic acalculous cholecystitis may be accompanied by the appearance of urticaria, Quincke's edema, drug and food allergies, and sometimes bronchospasm, arthralgia, and eosinophilia.

In practical terms, it is important to distinguish the "clinical masks" of chronic acalculous cholecystitis. They are characterized by the dominance of a certain group of symptoms in the clinical picture, which sometimes complicates the correct diagnosis of the disease. The following "clinical masks" are distinguished:

• "gastrointestinal" (dyspeptic complaints predominate, typical pain syndrome is absent);
• "cardiac" (cardialgia and reflex angina come to the fore, especially in men over 40 years of age. This form requires careful differential diagnosis with coronary heart disease);
• "neurasthenic" (with pronounced neurotic syndrome);
• "rheumatic" (with the prevalence of subfebrile temperature, palpitations and interruptions in the heart area, arthralgia, sweating, diffuse changes in the ECG in the clinical picture of the disease);
• "thyrotoxic" (with increased irritability, tachycardia, sweating, hand tremors, weight loss);
• "solar" mask (characterized by the predominance of symptoms of solar plexus damage in the clinic).

Objective examination of the patient

Inspection

Some patients may have subicteric (and sometimes more pronounced yellowness) of the sclera and skin. In chronic acalculous cholecystitis, this is due to concomitant hypertonic dyskinesia of the biliary tract and spasm of the sphincter of Odzi and, consequently, temporary cessation of bile flow into the duodenum. In some patients, yellowness of the skin and sclera may be due to concomitant chronic hepatitis.

With concomitant liver cirrhosis or severe chronic hepatitis, "spider veins" (telangiectasias in the form of spiders, red droplets) can be found on the skin of the chest. In the area of the right hypochondrium, a pigmentation zone is sometimes visible (traces of frequent use of a heating pad) with severe pain syndrome. This symptom is more characteristic of chronic calculous cholecystitis.

Most patients are found to be overweight.

Palpation and percussion of the abdomen

Palpation reveals localized pain in the area of the gallbladder - the intersection of the outer edge of the right rectus abdominis muscle with the right costal arch (Ker's symptom). This symptom is observed in the acute stage of chronic acalculous cholecystitis, with the development of pericholecystitis, with the hyperkinetic type of biliary dyskinesia, and also with stretching of the gallbladder with its hypotension or atony.

If normal deep palpation does not reveal pain in the gallbladder area, it is recommended to determine Murphy's symptom - pain during palpation of the gallbladder area with a deep breath and some abdominal retraction.