Chronic cholecystitis: symptoms

Chronic galloping cholecystitis symptoms are widespread, which occurs in people of different ages, but still more often in middle-aged people - 40-60 years.

In persons older than 75 years, calculous cholecystitis predominates. Both calculous and calculous cholecystitis women are more likely to suffer than men.

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

Subjective symptoms of chronic cholecystitis

Pain

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

Pain in chronic, effeminate cholecystitis is usually localized in the region of the right hypochondrium, sometimes in the epigastric region. The appearance or intensification of pain is usually associated with abundant food, eating fatty, fried, spicy, too cold or hot food, carbonated drinks, alcohol. Often the pain is provoked by intense physical exertion or psychoemotional stressful situations. Chronic galloping cholecystitis is almost always accompanied by dyskinesia of the gallbladder. In the hypotonic version of dyskinesia, pain in the right side is usually constant, aching, usually not reaching great severity. Sometimes it is not so much pain that disturbs as much as a sense of heaviness in the right hypochondrium.

With concomitant hypertensive dyskinesia of the gallbladder, the pain is paroxysmal, it is quite intense, which is associated with a spastic contraction of the musculature of the gallbladder. Extremely severe pain (biliary colic attack), as a rule, are observed with calculous or "cervical" cholecystitis (preferential localization in the region of the cervix of the gallbladder.

Pain with a chronic, impotent cholecystitis radiates to the right shoulder, right shoulder blade, sometimes to the collarbone. The origin of the pain is associated with a spasm of the gallbladder musculature, an increase in pressure in it (with hypertensive dyskinesia), or a dilatation of the gallbladder, which is also accompanied by an increase in intravesical pressure.

When complicating chronic cholecystitis with pericholecystitis, the pain acquires the character of so-called somatic pain. It is caused by irritation of the parietal peritoneum, subcutaneous tissue, skin, interned by sensitive spinal nerves. Pain with pericholecystitis is permanent, but it increases with bends and torso, sharp movement with the right hand. It can be more common and localize in the liver. With the development of chronic pancreatitis, the pain may become shrouded, irradiate into epigastrium, the left hypochondrium, sometimes into the peripodal region; when complicated by reactive hepatitis - the pain is localized in the region of the entire liver.

Dyspeptic complaints

In the period of exacerbation of chronic cholecystitis, dyspeptic complaints are often troubled. Vomiting is observed in 30-50% of patients and can be caused by concomitant gastroduodenitis, pancreatitis. When combined with hypotonic dyskinesia of the gallbladder after vomiting, there may be a reduction in pain and a feeling of heaviness in the right hypochondrium, with hypertonic dyskinesia, vomiting increases pain. In vomit masses, a bile impurity can be detected. Vomiting, like pain, is provoked by drinking alcohol, dietary inaccuracies.

In the period of exacerbation of chronic stoneless cholecystitis, patients are often disturbed by nausea, bitterness in the mouth, bitter eructation (especially with accompanying hypotonic dyskinesia of the gallbladder). As a result of the development of secondary gastroduodenitis, gastritis, pancreatitis, enteritis, there are heartburn, belch "rotten", flatulence, decreased appetite, diarrhea.

[6], [7], [8], [9]

Itchy skin

Symptom, reflecting a violation of bile secretion and irritation of nerve endings of the skin with bile acids. The most typical for cholelithiasis, the syndrome of cholestasis, but sometimes it can occur with noncalculous cholecystitis due to congestion of bile.

Increased body temperature

It is noted in the period of exacerbation of chronic cholecystitis in 30-40% of patients, It can be accompanied by cognition.

Psychoemotional disorders

Depression, general weakness, fast fatigue, irritability, emotional lability in chronic efflorescence of cholecystitis are due not only to the disease itself, but also to psychotraumatic effects, as well as somatogenic complications 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 in the period of exacerbation, pain in the heart region of the reflex genesis is possible.

[10], [11]

Symptoms of Chronic Cholecystitis: Species

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

1. Viscero-muscular reflex painful points and zones - are characterized by the fact that the pressure of the finger on the organ-specific points of the skin causes pain:
   • the Mackenzie pain point is located at the intersection of the outer edge of the right rectus abdominis with the right costal arch;
   • Boas pain point - localized on the posterior surface of the thorax along the paravertebral line to the right at the level of the X-XI thoracic vertebrae;
   • zones of cutaneous hypertension Zakharyin-Ged - vast areas of severe soreness and hypersensitivity, spreading in all directions from the points of Mackenzie and Boas.
2. Cotanno-visceral reflex symptoms are characterized by the fact that exposure to certain points or zones causes pain going inward towards the gallbladder:
   • a symptom of Aliyev - pressure on the points of Mackenzie or Boas causes not only local soreness directly under the palpating finger, but also pain going inward towards the gallbladder;
   • symptom of Eisenberg-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 soreness, feels a pronounced irradiation deep into the gallbladder's area.

Chronic cholecystitis symptoms of the first group are regular and characteristic for exacerbation of chronic cholecystitis. The most pathognomonic are the symptoms of Mackenzie, Boas, Aliev.

Chronic cholecystitis symptoms of the second group are due to the spread of irrigation of the autonomic nervous system beyond the segmentary innervation of the biliary system to the entire right half of the body and right limbs. At the same time, a right-sided reactive vegetative syndrome is formed, characterized by the appearance of painful sensations upon palpation of the following points:

• orbital point of Bergman (near the upper-inner edge of the orbit);
• the occipital point of Jonas;
• point Mussi-Georgievsky (between the legs of the right m.sternocleidomastoideus) - right-hand frenicus-symptom;
• inter-flap point Kharitonov (in the middle of a horizontal line drawn through the middle of the inner edge of the right scapula);
• The femoral point of Lapinsky (the middle of the inner edge of the right thigh);
• the point of the right popliteal fossa;
• plantar point (at the rear of the right foot).

The pressure on these points is made with the tip of the index finger.

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

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

• Murphy's symptom - the doctor during the exhalation of the patient carefully immerses the tips of the four half-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 him due to pain contact of the fingertips with a sensitive inflamed gallbladder. Thus on the face of the patient there can be a grimace of a pain;
• symptom Kera - pain in the right hypochondrium in the zone of the gallbladder with deep palpation;
• symptom Gausmat - the appearance of pain with a short stroke of the palm below the right costal arch at the height of inspiration);
• symptom Lepene-Vasilenko - the appearance of pain when applying abrupt strokes with the tips of the fingers on the inspiration below the right costal arch;
• a symptom of Ortner-Grekov - the appearance of pain when the right rib arch is effaced with the edge of the palm (the pain appears due to the concussion of the inflamed gallbladder);
• symptom of Eisenberg-II - in the standing position the patient rises to the toes and then quickly descends to the heels, with a positive symptom there is pain in the right hypochondrium due to concussion of the inflamed gallbladder.

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

Gallbladder with chronic effeminate cholecystitis is not increased, with the development of secondary hepatitis percutaneously and palpation is determined by the increase in the liver (little expressed).

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

With a prolonged course of chronic cholecystitis, it is possible to involve the solar plexus in the pathological process - a secondary solar syndrome. The main signs of the solar syndrome are:

• pain in the navel with irradiation in the back (solarol), sometimes the pain is burning;
• dyspeptic phenomena (they are difficult to distinguish from the symptoms of dyspepsia due to exacerbation of the most chronic cholecystitis and concomitant pathology of the stomach);
• palpatory revealing of painful points located between the navel and the xiphoid process;
• a symptom of Pekarsky - soreness with pressure on the xiphoid process.

Some women suffering from chronic cholecystitis may develop a premenstrual tension syndrome, which manifests itself in neuropsychiatric, 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 due to hormonal imbalance (excessive estrogen levels, insufficient progesterone, activation of the renin-angiotensin II-aldosterone system, prolactin excess, endorphins secretion in the brain). The main clinical manifestations of the premenstrual tension syndrome are mood instability (depression, irritability, tearfulness), headaches, pastosity of the face and hands, soreness and soreness of the mammary glands, numbness of the hands and feet, fluctuations in blood pressure. In the same period there is an exacerbation of chronic cholecystitis.

Often, patients with chronic cholecystitis develop cholecysto-cardial syndrome, which is manifested by pain in the heart (usually unintentional, appearing after drinking alcohol, fatty and fried foods, sometimes with constant pains); palpitations or irregularities in the heart; transient atriovescricular blockade of I st; ECG-signs of diffuse changes in the myocardium (a significant decrease in the amplitude of the T wave in many leads). Reflex, infectious-toxic effects on the heart, metabolic disturbances in the myocardium, dysfunction of the autonomic nervous system are important in the formation of this syndrome.

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

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

• "Gastrointestinal" (dyspeptic complaints prevail, there is no typical pain syndrome);
• Cardial (cardialgia, reflex angina, especially in men after age 40. This form requires careful differential diagnosis with ischemic heart disease);
• "Neurasthenic" (with a pronounced neurotic syndrome);
• "Rheumatic" (with prevalence in the clinical picture of the disease subfebrile condition, palpitations and irregularities in the heart, arthralgia, sweating, diffuse ECG changes);
• "Thyrotoxic" (with increased irritability, tachycardia, sweating, the appearance of tremor of hands, weight loss);
• "Solar" mask (characterized by the prevalence of symptoms of the solar plexus in the clinic).

Objective study of the patient

Inspection

In some patients, subcline (and sometimes more pronounced icterus) may occur in sclera, 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, a temporary cessation of bile flow into the 12-colon. In some patients, jaundice of the skin and sclera may be due to concomitant chronic hepatitis.

With concomitant cirrhosis of the liver or severe chronic hepatitis, it is possible to detect "spider veins" (telangiectasia in the form of spiders, red droplets) on the skin of the chest. In the region of the right hypochondrium, sometimes a zone of pigmentation (traces of frequent use of a warmer) is visible in severe pain syndrome. This feature is more typical for chronic calculous cholecystitis.

In most patients, excess body weight is determined.

Palpation and percussion of the abdomen

Palpation reveals local soreness in the area of the gallbladder - the intersection of the outer edge of the right rectus abdominis with the right costal arch (Kehr's symptom). This symptom is observed in the stage of exacerbation of chronic acalculous cholecystitis, with the development of pericholecystitis, hyperkinetic type of dyskinesia of the bile ducts, and also with the dilatation of the gallbladder with its hypotension or atony.

If the usual deep palpation does not reveal pain in the area of the gallbladder, it is recommended to determine the symptom of Murphy - tenderness when palpating the area of the gallbladder with a deep inspiration and some retraction of the abdomen.