Dyskinesia of bile ducts in children

Dyskinesia of bile ducts in children - disorders of gallbladder motility and sphincter apparatus of the biliary system, clinically manifested by pain syndrome, a complex of functional disorders lasting more than 3 months, accompanied by abdominal pain localized in the right upper quadrant. This is the most common and early pathology of the biliary system in children.

The sphincter apparatus of the biliary tract includes:

• Lutkens sphincter located at the site of the confluence of the bladder duct into the neck of the gallbladder;
• sphincter Mirizzi, located at the junction of the vesicle and common bile ducts;
• Sphincter One, located at the end of the common bile duct in place of its confluence with the duodenum.

Synonyms: Dysfunctional disorders of the bile excretory system, hypertensive dyskinesia of the sphincter of Oddi, spasm of the sphincter of Oddi. 

ICD-10 code

K82.0. Dysfunctional disorders of the bile excretory system.

Epidemiology

Statistical data, based on the principles of evidence-based medicine, has not been collected to date. The data on the incidence of dysfunction in the biliary system in children are based on the account of clinical dysfunctions that cause frequent visits to the pediatrician and occupy the second place among gastrointestinal diseases. The incidence of hypomotor dyskinesia of the gallbladder in children varies from 40 to 99%.

[1], [2], [3]

Causes of biliary dyskinesia in children

Violations of the functioning of the gallbladder often occur against a background of general neurosis, diencephalic vegetative crisis, viral hepatitis, other infections and intoxications. It is assumed that various anomalies in the development of bile ducts serve as one of the main factors of dysfunction of the biliary tract.

As an important reason for the sphincter of Oddi, many authors consider cholecystectomy. Removal of the gallbladder leads to a violation of the deposition of bile and the regulation of motor activity in the sphincter of Oddi. Free, constant release of bile into the duodenum provokes the development of duodenitis, an increase in the frequency of duodenogastric reflux, stimulates the motility of the gastrointestinal tract. Dyskinesia of the duodenum, especially in the hypertonic type, often causes a spastic contraction of the sphincter of Oddi, which prevents the normal outflow of bile.

Bile ducts are often involved in the pathological process in primary lesions of the fecal nipple and sphincter of Oddi (for example, with stenosis of the large duodenal papilla). Stenosing duodenal papillitis can form again against a background of acute or exacerbated chronic pancreatitis, peptic ulcer of duodenum and other diseases.

The provoking factors of biliary dyskinesia are:

• food errors (especially abuse of fried and fatty foods);
• intestinal parasitosis (especially giardiasis);
• a number of infections (acute hepatitis, salmonellosis, dysentery);
• food allergy;
• duodenitis, peptic ulcer, liver disease, intestines, dysbiosis;
• inadequate level of physical and psychoemotional loads.

[4], [5], [6], [7]

Pathogenesis of biliary dyskinesia in children

The motor activity of the gallbladder, sphincter of Oddi and other parts of the gastrointestinal tract is interrelated. Due to coordination of the contractile activity of the gallbladder, the migrating motor complex and the sphincter of Oddi, the gallbladder becomes filled in the interval between meals. In the regulation of the contractile activity of the sphincter of Oddi participate:

• Visceral-visceral reflexes caused by the extension of hollow organs during digestion and under the influence of food components;
• humoral factors (cholecystokinin, gastrin, secretin);
• neurotransmitters vaso-intestinal polypeptide and nitric oxide, which cause relaxation of smooth muscle cells of the biliary tract, as well as acetylcholine and tachykinins, contributing to the reduction of smooth muscle cells;
• y-aminobutyric acid and somatostatin are stimulated, and opioid peptides inhibit the release of relaxing mediators;
• endogenous opiates when bound to opioid receptors of myocytes stimulate motor activity, and when bound to k-receptors, they reduce it.

The pressure gradient between the duct system and the duodenum regulates the sphincter of Oddi. Episodes of increasing the tone ("blocking activity") of the sphincter of Oddi are accompanied by a passive expansion of the gallbladder, a marked increase in pressure in the biliary tract does not occur. However, the gallbladder is able to play the role of a buffer reservoir only in cases of preservation of its contractile function. Violation of coordination in the work of the sphincter of Oddi and the gallbladder leads to an increase in pressure in the bile excretory system and the formation of a pain syndrome of varying intensity. Spasm of the sphincter of Oddi in combination with an increase in the tone of the gallbladder leads to a sharp increase in pressure in the duct system, the development of acute pain in the abdomen. The spasm of the sphincter of Oddi in combination with the atony of the gallbladder contributes to the slow build-up of pressure, accompanied by a dull ache in the abdomen. Insufficiency of the sphincter of Oddi and hypotension of the gallbladder lead to self-extinction of bile in the duodenum with the appearance of a sphincteritis, etc. Variants of discoordination of the gallbladder and sphincter of Oddi are numerous, the pathogenesis of these disorders is complicated and insufficiently studied.

What leads to biliary dyskinesia?

Symptoms of biliary dyskinesia in children

The group of general symptoms of dyskinesia bile ducts include fatigue, irritability, decreased performance in schoolchildren, tearfulness in preschool children. Some children experience motor disinhibition, others have hypodynamia, sweating, palpitations and other symptoms are possible. The connection between deterioration of well-being and psychosocial factors is established. Significantly affect the state of patients features of character, children from this group are characterized by good faith, punctuality, compulsion, vulnerability, suspicion, high standards for personal hygiene, self-incrimination and isolation.

With dysfunctions of the bile excretory system due to gastrointestinal diseases, the child is troubled by a feeling of heaviness in the epigastric region, nausea, vomiting, belching, bitterness in the mouth. Changes in the frequency of stool and other disorders, the occurrence of which is associated with the late release of bile into the duodenum, a violation of the digestion of fats, duodenogastric and gastroesophageal reflux, etc.

Functional disorders of the biliary tract in children are closely interrelated with vegetative dysfunctions, as a result of which they manifest in the preschool age, progress in the early school period, and at the age of more than 10 years can be registered as a disease. The most stable sign of dysfunction of the biliary tract is abdominal pain, various in origin, duration, periodicity, localization, intensity.

With hyperfunction of the gallbladder (hyperkinetic form), there are pains of paroxysmal nature, stitching, cutting, compressing, accompanied by nausea, eructation, vomiting. In the interval between attacks, children do not complain.

With hypofunction of the gallbladder (hypotonic form), the pains acquire a constant pressing character, periodically amplified. Characterized by a feeling of bursting or heaviness in the right hypochondrium. Cerea, Ortner, Boas and others can have vesicular symptoms. Children complain of bitterness in the mouth, nausea, and sometimes vomiting occurs.

Hyperfunction of the sphincter of Oddi can lead to acute pain in the right hypochondrium, reminiscent of the intensity of biliary colic, accompanied by nausea and vomiting, jaundice is possible sclera and skin.

If the sphincter is deficient, Oddi's child is disturbed by early pain after taking fatty foods, combined with nausea and vomiting, belching and heartburn are possible.

None of the described symptoms are pathognomonic for dysfunctional disorders of the biliary tract, and therefore the setting of a clinical diagnosis for a doctor of outpatient practice is extremely difficult.

Symptoms of biliary dyskinesia

Classification

Roman criteria III (2006) in the section "Functional disorders of the gall bladder and sphincter of Oddi" include the following headings.

• E - functional disorders of the gall bladder and sphincter of Oddi.
• E1 - functional disorder of the gallbladder.
• E2 - functional biliary disorder of the sphincter of Oddi.
• E3 - functional pancreatic disorder of the sphincter of Oddi.

In comparison with the Roman criteria II, changes are associated with a strict limitation of the number of unnecessary invasive procedures and surgical interventions in patients with pain in the upper abdomen. Biliary and pancreatic pain should be determined by localization, severity, timing, duration and association with typical symptoms of GERD, functional dyspepsia and irritable bowel syndrome.

[8], [9], [10], [11], [12], [13]

Screening

Ultrasonography of the gallbladder with the study of the contractile function allows us to establish the type of dysfunction. The condition of the sphincter of Oddi is determined in hepatobiliary scintigraphy.

Diagnosis of biliary dyskinesia

When collecting anamnesis, specify the nature, frequency and localization of pain. At objective research estimate color of integuments, the sizes of a liver, color of a chair and urine. It is extremely rare to detect pinpoint symptoms (Ortner, Kera, etc.).

[14], [15], [16]

Laboratory research

By the results of biochemical analysis of blood serum, the activity of enzymes - cholestasis markers (alkaline phosphatase, y-glutamyltranspeptidase) can be increased.

Instrumental research

The Oddi sphincter manometer with separate cannulation of the bile and pancreatic segments, considered the "gold standard" for diagnosing dysfunctions of the biliary tract, is not used in children due to invasiveness, traumatism and the possibility of complications.

The diameter of the bile duct can be measured with ultrasound. An increase in the diameter of the common bile duct after fatty food or the introduction of cholecystokinin reflects a violation of the outflow of bile, which may indicate a dysfunction of the biliary tract.

The most acceptable for practical use in children is considered hepatobiliary scintigraphy, if necessary supplemented by pharmacological tests (neostigmine morphine, the introduction of the relaxant nitroglycerin).

Scanning is started after the introduction of imidodiacetyl acid preparations labeled with technetium (Tc). After 1 hour, the maximum activity of the drug is fixed in the bile ducts, gall bladder and duodenum, and minimal in the liver. A close correlation between the results of the cholescintigraphy and the manometric study of the sphincter of Oddi is proved.

Differential diagnostics

Functional disorders of the bile excretory system are differentiated with a sharp stomach, an attack of biliary colic, acute pancreatitis and cholecystitis. Hypotonic conditions and deficiency of the sphincter of Oddi can be similar to chronic diseases of the stomach, duodenum, chronic pancreatitis.

Acute cholecystitis (acute cholecystocholangitis) - acute inflammation of the gallbladder. Occurs in infants rarely, boys are 2 times more likely than girls. The most important predisposing condition is stasis of bile in the gallbladder, for example, with developmental anomalies.

Characteristic:

• sudden fever to febrile;
• cramping pain in the right side, and sometimes throughout the abdomen. A bout of pain can last from a few minutes to several hours. Pain is worse in the position on the right side;
• nausea and vomiting;
• the phenomena of intoxication: the skin is pale, moist, lips and mucous membranes of the mouth dry, tongue is covered, headache, lack of appetite, stool retention, tachycardia;
• possibly (in 50% of cases) the appearance of jaundice.

When examining the abdomen, note some of its swelling, lagging of the upper parts during breathing. When palpation is found the rigidity of the muscles of the anterior abdominal wall to the right, more in the upper parts and in the hypochondrium. As a rule, the symptoms of Mendel, Ortner, Murphy are positive. Often positive is the symptom of Shchetkin-Blumberg. When analyzing blood in patients, leukocytosis with neutrophileosis, increased ESR, is revealed.

The course of acute cholecystitis in children is usually benign, but in most cases acute cholecystitis is the beginning of chronic cholecystitis.

Chronic cholecystitis is a recurrent inflammatory disease of the gallbladder. Often, chronic cholecystitis is formed after a hepatitis, often accompanies cholelithiasis and duodenobiliary reflux. Predisposing factors to the development of cholecystitis are bile duct anomalies, discololia, and dysbacteriosis. In children it is rare.

Unlike dyskinesia, clinical manifestations of cholecystitis are characterized by stereotypedness, the presence of periods of exacerbations with severe intoxication, possible subfebrile condition.

For chronic cholecystitis in children are characterized by:

• right-sided rib syndrome,
• dyspepsia, inflammatory-intoxication, asthenovegetative, cholestatic syndromes.

Differential diagnostic criteria for bile duct disease in children

Criterion	Chronic cholecystocholangitis	Cholelithiasis
Anamnesis Family predisposition Seasonality of exacerbation Duration of the disease	Weakness, lethargy, signs of intoxication, polyhypovitaminosis Typical Autumn-spring period 1,5-2 years	Pre-existing diseases of the biliary system Typical Not typical Long term (undefined)
Pain syndrome: Constant pains Relationship with inaccuracies in the diet Paroxysmal pain Soreness in the right hypochondrium Irradiation	Characteristic After 1,5-2 hours after eating, especially greasy and fried Characteristic at exacerbation Typical In the right shoulder and shoulder blade	Not typical Immediately after eating Characterized by colic Characteristic in colic Also
Ultrasound	Thickening, hyperechoic wall of the bladder, heterogeneity of the contents	Movable hyperechoic formation in the bladder with echoes

Of the objective symptoms of cholecystitis in children, most often found are: muscle resistance in the right hypochondrium, Ortner's symptom, Murphy's symptom, Mendel's symptom, tenderness of palpation in the Schofar triangle.

At laboratory researches at a cholecystitis parameters of activity of inflammatory process (a hypergammaglobulinemia, a hyperfibrinogenemia, rising SOE, a leukocytopenia) can be raised.

In ultrasound examination, the evidence for cholecystitis is the detection of a thickened (more than 1.5 mm), layered, hyperechoic gallbladder wall, as well as heterogeneity of bile.

With thermal imaging, hyperthermia is detected in the area of the gallbladder projection.

Diagnosis is significant change in the composition of yelp:

• reduction of arachidonic and oleic acids, increase of pentadecane and copper fatty acids;
• increase in the concentration of immunoglobulins G and A, R-proteins, C-reactive protein;
• increase of enzymes (5-nucleotidase and alkaline phosphatase);
• decreased lysozyme.

There may be an increase in the blood transaminases, bilirubin and beta-lipoproteins.

Gallstone disease is a dystrophic-dysmetabolic disease characterized by the formation of stones in the yellow bladder or in the yellow ducts.

The cause for children can be:

• diseases that occur with increased hemolysis;
• familial hypercholesterolemia;
• hepatitis and inflammatory lesions of the biliary system;
• factors leading to the development of cholestasis (eg, cystic fibrosis);
• diabetes.

In the pathogenesis, bile stasis, discololia, inflammation are important.

In most cases, cholelithiasis in children has a latent course. The clinical picture is manifested either by symptoms of cholecystitis, or by symptoms of bile duct obstruction - biliary colic. Complications (dropsy, empyema or gall bladder gangrene) in children are rare.

In the diagnosis, a leading role is played by sonography, roentgencholecystography, computer tomography. To clarify the composition of concrements, it is expedient to study the composition of bile.

Diagnosis of biliary dyskinesia

[17], [18], [19], [20], [21], [22]

Treatment of biliary dyskinesia in children

Treatment of patients with diseases of the biliary system should be comprehensive, step-by-step and maximally individual.

Therapeutic tactics define:

• the nature of dyskinetic disorders;
• condition of the cholego-choledochondoduodenal zone;
• severity of vegetative reactions.

Methods of treatment of biliary dyskinesia in children

1. Mode.
2. Dietotherapy (table number 5).
3. Medication:
   • choleretics;
   • cholekinetics;
   • choleospasmolytics; phytotherapy;
4. treatment with mineral waters; physiotherapy;
5. Spa treatment.

How are bile duct dyskinesias treated?

Dietotherapy

Multiple meals were shown during the day (5-6 times), exclusion of fried foods, chocolate, cocoa, coffee, strong broths, smoked products, carbonated drinks. In the hypertensive form of dyskinesia, fractional nutrition is recommended with the restriction of products that cause a reduction in the bladder - fatty meat, fish, poultry, fatty foods, broths, garlic, onions, marinades, smoked products, peas and beans. In the hypotonic form of dyskinesia, the diet should include fruits, vegetables, vegetable and butter, sour cream, cream, eggs.

[23], [24], [25]

Medication Therapy

One of the leading places in the complex therapy of patients with dyskinesia of the bile ducts is the administration of cholagogue. All choleretic preparations are classified as follows.

1. Drugs that stimulate the bile-forming function of the liver (choleretics).
2. Drugs that increase the formation of bile and stimulate the formation of bile acids,
   • true choleretics;
   • preparations containing bile acids (decholin, chologon, allochol, etc.);
   • synthetic preparations (nicodine, osalmide, cycloalone);
   • preparations of plant origin containing sandy immortelle, mint, St. John's wort, turmeric, etc. (flamin, cholago, holaflux, holagogum).
3. Drugs that increase the secretion of bile mainly due to the water component (hydrocholeretics), - mineral waters, corn stigmas, valerian preparations, etc.
4. Medicinal products that affect the bile excretory function of the liver.
5. Drugs that cause an increase in the tone of the gallbladder and a decrease in the tone of the biliary tract (cholekinetics), cholecystokinin, magnesium sulfate, xylitol, herbal preparations from barberry, and turmeric (including holagogum).
6. Drugs that cause relaxation of the biliary tract (chol spasmolytics), - papaverine, atropine, extract of belladonna and mint.

Cholagogue therapy should be carried out for a long time, intermittent courses, systematically alternating cholagogue, which prevents the dystrophy of hepatocytes and the addiction of the body to drugs.

When choosing a drug, it is necessary to consider:

• type of dyskinesia;
• the initial tone of the gallbladder and sphincter apparatus. Correction of motility of the biliary tract begins with a search for the cause and its elimination, the treatment of the underlying disease and normalization of the vegetative status are carried out.

With increased motor skills use antispasmodics, sedatives, phytotherapy, physiotherapy.

With reduced motor skills, they carry out tjubazhi, use tonic means, use cholekinetics.

Tubazhi with various stimulants is a highly effective cholekinetic agent. Often apply tjubazh with mineral water: 100-150 ml of warm mineral water without gases the patient drinks on an empty stomach, then lies down on the right side, under which a warm heating pad is put, for 45 min. Additional components can be added to the mineral water (sorbitol, magnesium sulfate, Barbara salt). The course consists of 10 procedures (1 time in 3 days).

Many plants have a choleretic and cholekinetic effect: ayr marsh, artichoke, barberry, sandless immortelle, corn stalks and buds, burdock stems, burdock root, bitter wormwood, radish sowing, mountain ash, hops, lingonberry, marjoram, calendula officinalis, dandelion medicinal, rhubarb root. The medicinal origin of the artichoke is included in the preparation hofitol, released in the form of tablets and a solution, applied 3 times daily before meals. It is irreplaceable in the treatment of diseases of the gallbladder and biliary tract gimecromone. The drug has spasmolytic, choleretic effect, prevents the development of cholelithiasis by affecting the circulation of bile. Use 3 times a day for 30 minutes before meals at a dose of 100 mg for children under 10 years and 200 mg 3 times a day after 10 years.

Holospazmolytics are an important component of treatment. A special place is occupied by mebeverin (duspatalin). The drug has a dual mechanism of action, which prevents the development of hypotension - a side effect of spasmolytic therapy. Mebeverin blocks Na + channels, preventing the depolarization of the muscle cell and the development of spasm, disturbing the transfer of the pulse from the cholinergic receptors. On the other hand, it blocks the filling of Ca2 + depots, depleting them and limiting the yield of potassium ions from the cell, which prevents the development of hypotension. The drug has a modulating effect on the sphincters of the digestive system.

Some medicinal plants also possess a cholespismolytic effect: mountain arnica, valerian officinalis, elecampane high, St. John's wort, peppermint, dried herring, medicinal sage. To the preparations of plant origin are: flamin (apply, depending on the age, 1/4 1 tablet 3 times a day), holagogum (1 capsule 2 times a day), cholagol (1-5 drops, depending on the age, on sugar 3 times a day before meals), holosas (1 teaspoon 2-3 times a day, washed down with hot water).

Combined choleretics include: allochol (1-2 tablets 3 times a day, the preparation contains dry bile of animals, dry extract of garlic, activated charcoal), digestal (1-2 tablets 3 times a day during meals, contains pancreatin, bile extract, hemicellulase), festal (1 / 2- 1-2 tablets, depending on age, after eating 3 times a day, contains pancreatic enzymes, bile components), cholenzim (1 tablet 3 times a day, contains bile, dried pancreas , dried mucous membrane of small intestines of slaughter cattle).

Tea Holaflux promotes the formation and outflow of bile, has an antispasmodic effect. Tea composition: spinach leaves, thistle fruits, celandine grass, yarrow herb, licorice root, rhubarb rhizome, dandelion root, turmeric root and oil, aloe vera extract.

Neurotropic agents are prescribed taking into account the nature of dyskinesia and autonomic dysfunction. Toning means - caffeine, ginseng; sedative - bromides, tincture of valerian, tincture of motherwort. The choice of the drug should be discussed with the neurologist.

With hypertension of the biliary tract, hepatoprotectors are used to protect the liver and duct cells from the damaging effects of bile. Use drugs of chemical origin (ursodeoxycholic acid, methionine, essential phospholipids), plant origin (milk thistle, turmeric, artichoke, pumpkin seeds), as well as hepabene and pumpkin (1 teaspoon 3 times a day for 30 minutes before meals).