Chapter 5. DISEASES OF BILIARY TRACTS

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ANATOMY OF BILIARY TRACTS

CLASSIFICATION OF DISEASES OF THE BILIARY SYSTEM

DYSKINESIA OF BILIARY TRACTS

Dyskinesia of the biliary tracts and gallbladder is a discoordinated, excessive or reduced function of the gallbladder and Oddi's sphincter representing a functional disorder resulting in the bile outflow impairment. In hypokinetic form it manifests with dyspeptic phenomena and aching pain. In hyperkinetic form it manifests with acute colicy pain.

Diagnostics
	Hyperkinetic form	Hypokinetic form
Complaints	Attacks of acute pain in the right hypochondrium, epigastrium, nausea, sometimes vomiting	Aching pain in the right hypochondrium and epigastrium, nausea, bitter taste in the mouth, liquid stools
Anamnesis	Dietary errors, diseases of the gastro-intestinal tract (GIT), emotional disorders
Physical examination	Moderate tenderness at palpation in the right hypochondrium and epigastrium
Laboratory findings	Moderate hyperbilirubinemia
Instrumental studies	Ultrasonic investigation (US): persistent spasm of the gallbladder	US: persistent atony of the gallbladder
Treatment
Hyperkinetic form	Hypokinetic form
Diet excluding fatty, fried, pungent foods. Fractional food intake.
Spasmolytics, analgetics	Cholagogues
Dyskinesia is often the trigger mechanism of stone formation, cholecystitis, cholangitis, pancreatitis (bombarding of duodenal contents, bile congestion).

CHOLELITHIASIS

Definition and statistical data
Cholelithiasis is a systemic pathology characterized by formation of stones in the biliary system, mainly in the gallbladder, caused by dyskinesia of the biliary tracts, infection and disturbance of cholesterol and calcium metabolism.	It affects 10-20% of the population of the developed countries. It occurs in women 50 times more frequently than in men. People suffering from obesity are affected more frequently. Recently there is observed the increase of the number of patients with cholelithiasis. Representatives of the black race are affected rarely.

ACUTE CHOLECYSTITIS

Definition and statistical data

Acute cholecystitis is a disease which clinical course is conditioned by acute inflammation of the gallbladder.

In Russian Federation cholecystitis is found in 10-15% of the population. Acute cholecystitis occurs in people of various age groups, people above 50 years old being affected more frequently. Elderly and senile patients account for more than a half of the total number of patients with cholecystitis. The ratio of the disease developing in men and women is 1:5.

In the structure of urgent pathology of the abdominal cavity acute cholecystitis takes the second place after acute appendicitis.

Differential diagnostics

Acute cholecystitis should be differentiated from other acute diseases of the abdominal organs in atypical clinical picture (acute appendicitis, acute pancreatitis, perforating ulcer, mesenteric thrombosis, intestinal obstruction), as well as from the diseases of the thoracic organs (thoraco-abdominal syndrome in pneumonias, pleurites, lung cancer). Sometimes it is necessary to differentiate acute cholecystitis from the diseases of the heart (angina pectoris, infarction of the posterior wall).

In mechanical jaundice it is necessary to differentiate acute cholecystitis from other diseases causing jaundice (hepatitis, cirrhosis, cancer of the pancreas, etc.). Knowledge of clinical manifestations of the differentiated diseases, as well as modern reliable instrumental studies contribute to the accurate diagnostics of the disease.

Medicamentous treatment
Purposes	Means	Criteria of effectiveness
Liquidation of acute inflammation	Anti-microbial preparations: antibiotics of a wide spectrum of action in combination with metronidazol, fluoroquinolons.	Clinical improvement. Decrease of leukocytosis, temperature. Positive dynamics according to the USI data.
Liquidation of bile hypertension	Diet. Spasmolytics.
Detoxication	Intravenous infusions of blood substitutes of hemodynamic and detoxication action. Forced diuresis.
Liquidation of pain	Non-narcotic analgetics
Treatment of complications	In biliary pancreatitis - anti-enzymatic preparations, proton pump blockers. In mechanical jaundice - hepatoprotectors, correction of hemostatis.	Decrease of amylase, transaminases, normalization of hemostasis.
Correction of the comorbid pathology	In atherosclerosis and hypertensive disease - hypotensive, cardiac preparations. In diabetes mellitus - insulin therapy.	Normalization of arterial pressure (AP), cardiac output, blood glucose level.
Methods of surgical treatment of acute cholecystitis are analogous to those in chronic cholecystitis and will be described in the section "Surgical treatment of acute and chronic cholecystitis".

CHRONIC CHOLECYSTITIS

COMPLICATIONS

Differential diagnostics

It is carried out between other diseases of the abdominal organs in atypical clinical picture (chronic pancreatitis, ulcerous disease of the stomach and duodenum, cancer of the gallbladder, cancer of the hepatic angle of the colon). In mechanical jaundice it is necessary to carry out differentiation from other types of jaundice (in hepatitis, cirrhosis, cancer of the pancreas, etc.).Knowledge of the clinical picture of the differentiated diseases, as well as modern reliable instrumental methods, contributes to the accurate diagnostics.

TACTICS OF TREATMENT

Chronic calculous cholecystitis and stone-free chronic cholecystitis in the gallbladder atony are indications for planned surgical treatment. Chronic calculous cholecystitis complicated by cholangitis and jaundice, is the indication to the urgent operation. In accidental detection of stones in the gallbladder the question concerning the indication for surgical treatment should be solved individually depending on the patient's condition, probability of the development of complications (gallbladder contractile capability, size of stones, width of the cystic duct are of importance).

Other diseases of the biliary tracts
Nosologic units	Clinical picture	Diagnostics	Treatment
Cyst of the common bile duct (local widening of the common hepatic and common bile duct up to 15 cm)	Aching pain in the epigastrium and right hypochondrium, possibly - jaundice due to the accumulation of the thickened bile in the cystic cavity	US, CT, ERCP	Cystoduodeno- or cystojejunostomy with the anastomosis according to Roux on the long loop with dissection of the cystic walls
Polyps (singular and multiple)	These have no specific clinical picture	US, CT	These are indications to cholecystectomy due to a high probability of malignization
Cancer of the bile ducts	Jaundice without previous attack of pain, sometimes - an intermittent course due to the tumor lysis. Courvoisier's sign.	US, CT, ERCP	Dissection of the tumor, biliodigestive anastomosis. In disseminated cancer - pancreato-duodenal resection. Palliative operations - tumor recanalization on the drainage, bilio-digestive anastomoses
Cancer of Vater's papilla	Aching pain in the epigastrium and in the right hypocondrium. Jaundice, Courvoisier's sign.	Duodenography, fibro-gastroduodenoscopy (FGD) with biopsy	Papillectomy. In invasion of the tumor into the surrounding tissues - pancreatoduodenal resection (PDR). Palliative operations - biliodigestive anastomoses.