Cholecystopancreatoduodenal syndrome

The liver, bile ducts, gall bladder, pancreas, 12 duodenum are anatomically and functionally closely interrelated. Functional disorders or somatic diseases in one of these departments in most cases cause a disruption of function in other areas and the development of a symptom complex, defined as cholecysto-pancreato-duodenal syndrome, in which the clinic of the main pathological process that caused its formation prevails.

According to the functional morphological sign of the pathology of this zone of the digestive system can be divided into dysfunctional (spasmodic, occurring in the form of colic, dyskinesia, stagnating manifestations, reflux disorders), inflammatory, degenerative and mixed (inflammatory-degenerative, functional-inflammatory, etc.) . Separate graphs are malformations and tumors, which can also be manifested by this syndrome. According to the clinical course, the manifestations of the syndrome can be acute, subacute, chronic, transient.

Pathogenetic basis for the development of the disease is cholestasis - insufficiency of bile excretion as a result of its inadequate production by the liver cells (intrahepatic) or restriction of its admission to the 12-colon (subhepatic).

Intrahepatic cholestasis is manifested by the development of parenchymal jaundice, skin itching, no pain syndrome, splenomegaly is characteristic, the development of the disease is slow, more often observed in women prone to infectious and allergic diseases.

Subhepatic cholestasis develops equally often in both men and women. Clinical manifestations are very variable, but at the same time they serve for differential diagnosis of the process. First of all, it should be noted that cramping pains are characteristic of colic (when localized in the right hypochondrium are characteristic for hepatic colic, in the left hypochondrium or girdling for pancreatic colic, in the right hypochondrium and epigastrium - for duodenal colic, although isolated duodenospasm occurs extremely rarely, more often combined with hepatic colic due to a spasm of the sphincter of Oddi).

The transition of colic to organic pathology, is accompanied by the formation of permanent pain. Jaundice has a mechanical character, and the second major difference from intrahepatic cholestasis is the absence of splenomegaly. For cholelithiasis and inflammatory processes, the rapid development of the clinical picture is characteristic.

The pathology of the duodenum (dyskinesia, peptic ulcer disease) and faterovaya nipple (more often stricture) gives a slow development of the clinical picture.

Constant localization pain also indicates the defeat of a specific area of the cholecysto-pancreato-duodenal zone. In pancreatitis, they are shrouded or localized in epigastrium, right hypochondrium with local lesion of the gland head or in the left hypochondrium with damage to the tail; irradiate into the lumbar region, navel, can give in the left shoulder, under the scapula, in the heart area, imitating stenocardia, in the left iliac region. With cholecystitis, especially calculous pains are localized strictly in the right hypochondrium and have a more pronounced irradiation in the right shoulder, under the scapula, in the neck. Peptic ulcer is characterized by seasonality of exacerbations, night and "hungry" pains, their sharp decrease after y, food intake, soda and other antacid agents, vomiting, although they can be quite persistent with penetration into the head of the pancreas. When duodenitis pains in the upper abdomen at the level of the navel, intensify in the evening, at night, on an empty stomach or 1-2 hours after a meal, accompanied by heartburn and belching sour.

Cholecysto-pancreato-duodenal syndrome is accompanied by a variety of dyspeptic disorders, which are expressed in most cases, and which in most cases cause the patient to seek medical help: eructation, nausea, sometimes vomiting, intolerance to fatty and spicy food, bloating, constipation combined with diarrhea, or profuse diarrhea, weight loss, irritability, insomnia and other manifestations.

When infection of the bile duct (intrahepatic and extrahepatic) develops cholangitis. Isolated it happens rarely, often combined with cholecystitis (cholecystocholangitis) or hepatitis (hepatocholecystitis): Cholangitis distinguishes between acute and chronic. Acute is accompanied by a clinic of cholestasis, but with intense pains; and intoxication syndrome. After each attack of fever, jaundice increases. Often complicated by abscesses of the liver and subdiaphragmatic space, right-sided pleurisy, pericarditis, peritonitis, pancreatitis, cephis. As a result of hepatocholangitis, hepatic dystrophy may develop with cirrhosis, accompanied by the formation of portal hypertension and hepatic insufficiency.

Chronic cholangitis can develop primarily or be the outcome of an acute one. Typical deformation of nails in the form of hourglasses, hyperemia of the palms. The liver develops dystrophy (fatty, granular, amyloidosis), which in most cases go to cirrhosis.

With latent form of the disease, pain and tenderness in palpation in the right hypochondrium are not expressed or completely absent. Periodically disturbed by weakness, cognition, itchy skin, there may be a low-grade fever.

With recurrent form of cholangitis, pain syndrome and local manifestations are poorly expressed, only with the presence of cholelithiasis can severe pains occur. Exacerbation of the process is accompanied by fever, skin itch, sometimes jaundice. The liver is enlarged, dense, painful. Sometimes pancreatitis joins. Can be splenomegaly.

Often, hepatocholangitis is a group of infectious and allergic diseases, sometimes combined with ulcerative colitis (NNC), Crohn's disease (terminal ileitis), thyroiditis Ridel, vasculitis.

In a physical examination, a complex of additional symptoms characteristic of each disease is determined. At present, there are no difficulties for the diagnosis of cholecysto-pancreato-duodenal syndrome, an accurate topical diagnosis can be made rather quickly during FGS and abdominal ultrasound with subsequent complex of additional diagnostic studies (cholangiography, retrograde pancreatoholangiography with FGS, radioisotope study, etc.).

It must be remembered that cholecysto-pancreato-duodenal syndrome can be caused by opisthorchiasis, the incidence of which is increasing, and epidemiologists note the high infection of the Siberian fluke of all river and lake fish, in some areas even its catch and sale are prohibited. The morbidity rate also increases among tourists, especially when visiting Thailand, France, Italy, which are infected with a mollusk gusset. Opisthorchiasis; proceeds with a clinic of cholecystitis, cholangitis, pancreatitis. Confirms the diagnosis of feces for helminths. Duodenal sounding is not informative, since opisthorchia larvae are most often detected only after repeated studies.

In all cases of cholecysto-pancreato-duodenal syndrome, especially in the presence of jaundice, it is necessary to be wary of cancer of the pancreato-duodenal zone.

Jaundice is not accompanied by severe pain syndrome, has a transient (undulating) character, has a characteristic greenish tinge, accompanied by indomitable and not bringing relief vomiting. In these cases, magnetic resonance imaging must be performed.

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