Anatomy of the biliary system. Diseases of the biliary system

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The liver secret necessary for digestion moves through the gallbladder to the intestinal cavity through the bile ducts. Various diseases provoke changes in the functioning of the bile ducts. Interruptions in the work of these pathways affect the performance of the whole organism. The bile ducts differ in their structural and physiological features.

Interruptions in the work of the bile ducts affect the performance of the whole organism

What is the gallbladder for?

The liver is responsible for the secretion of bile in the body, and what function does the gallbladder perform in the body? The biliary system is formed by the gallbladder and its ducts. The development of pathological processes in it threatens with serious complications and affects the normal life of a person.

The functions of the gallbladder in the human body are:

  • accumulation of bile fluid in the cavity of the organ;
  • thickening and preservation of hepatic secretions;
  • excretion through the bile ducts small intestine;
  • protecting the body from irritants.

The production of bile is carried out by the cells of the liver and does not stop day or night. Why does a person need a gallbladder and why is it impossible to do without this link when transporting hepatic fluid?

The excretion of bile occurs constantly, but the processing of the food mass with bile is required only in the process of digestion, which is limited in duration. Therefore, the role of the gallbladder in the human body is to accumulate and store the secret of the liver until the right time. The production of bile in the body is an uninterrupted process and it is formed many times more than the volume of the pear-shaped organ allows. Therefore, bile splitting occurs inside the cavity, the removal of water and some substances necessary in other physiological processes. Thus, it becomes more concentrated, and its volume is significantly reduced.

The amount that the bubble will throw out does not depend on how much it produces the largest gland - the liver, which is responsible for the production of bile. The value in this case is played by the amount of food consumed and its nutritional composition. The passage of food through the esophagus serves as a signal to start work. To digest fatty and heavy foods, more secretions will be required, so the organ will contract more strongly. If the amount of bile in the bladder is insufficient, then the liver is directly involved in the process, where the secretion of bile never stops.

The accumulation and excretion of bile is carried out as follows:

Therefore, the role of the gallbladder in the human body is to accumulate and store the secret of the liver until the right time.

  • the common hepatic duct passes the secret to the bile duct, where it accumulates and is stored until the right moment;
  • the bubble begins to contract rhythmically;
  • the bladder valve opens;
  • the opening of the intracanal valves is provoked, the sphincter of the major duodenal papilla relaxes;
  • bile goes to the intestines through the common bile duct.

In cases where the bubble is removed, the biliary system does not cease to function. All work falls on the bile ducts. The innervation of the gallbladder or its connection with the central nervous system occurs through the hepatic plexus.

Gallbladder dysfunction affects the well-being and can cause weakness, nausea, vomiting, itchy skin and other unpleasant symptoms. In Chinese medicine, it is customary to consider the gallbladder not as a separate organ, but as a component of one system with the liver, which is responsible for the timely release of bile.

The meridian of the gallbladder is considered Jansky, i.e. paired and runs throughout the body from head to toes. The meridian of the liver, which belongs to the Yin organs, and the gallbladder are closely related. It is important to understand how it spreads in human body so that the treatment of organ pathologies with the help of Chinese medicine is effective. There are two channel paths:

  • external, passing from the corner of the eye through the temporal region, forehead and back of the head, then descending to the armpit and lower along the front of the thigh to the ring toe;
  • internal, starting in the area of ​​​​the shoulders and going through the diaphragm, stomach and liver, ending with a branch in the bladder.

Stimulation of points on the meridian of the biliary organ helps not only to improve digestion and improve its work. Impact on the points of the head eliminates:

  • migraines;
  • arthritis;
  • diseases of the visual organs.

Also, through the points of the body, you can improve cardiac activity, but with help. Areas on the legs - muscle activity.

The structure of the gallbladder and biliary tract

The gallbladder meridian affects many organs, which indicates that the normal functioning of the biliary system is extremely important for the functioning of the whole organism. The anatomy of the gallbladder and biliary tract is a complex system of channels that ensure the movement of bile inside the human body. To understand how the gallbladder works, its anatomy helps.

What is the gallbladder, what is its structure and functions? This organ has the shape of a sac, which is located on the surface of the liver, more precisely, in its lower part.

In some cases, during fetal development, the organ does not come to the surface of the liver. The intrahepatic location of the bladder increases the risk of developing cholelithiasis and other diseases.

The shape of the gallbladder has a pear-shaped outline, a narrowed top and an expansion at the bottom of the organ. There are three parts in the structure of the gallbladder:

  • narrow neck, where bile enters through the common hepatic duct;
  • body, widest part;
  • the bottom, which is easily determined by ultrasound.

The organ has a small volume and is able to hold about 50 ml of fluid. Excess bile is excreted through the small duct.

The walls of the bubble have the following structure:

  1. Serous outer layer.
  2. epithelial layer.
  3. Mucous membrane.

The mucous membrane of the gallbladder is designed in such a way that the incoming bile is very quickly absorbed and processed. In the folded surface there are many mucous glands, the intensive work of which concentrates the incoming fluid and reduces its volume.

The ducts perform a transport function and ensure the movement of bile from the liver through the bladder to the duodenum. Ducts run to the right and left of the liver and form into the common hepatic duct.

The anatomy of the gallbladder and biliary tract is a complex system of channels that ensure the movement of bile inside the human body.

The anatomy of the biliary tract includes two types of ducts: extrahepatic and intrahepatic bile ducts.

The structure of the biliary tract outside the liver consists of several channels:

  1. Cystic duct that connects the liver to the bladder.
  2. The common bile duct (CBD or common bile duct), which begins at the junction of the hepatic and cystic ducts and leads to the duodenum.

The anatomy of the biliary tract distinguishes between the sections of the common bile duct. First, bile from the bladder passes through the supraduodenal section, passes into the retroduodenal section, then enters the duodenal section through the pancreatic section. Only along this path can bile get from the organ cavity to the duodenum.

How the gallbladder works

The process of movement of bile in the body is triggered by small intrahepatic tubules, which unite at the exit and form the hepatic left and right ducts. Then they form into an even larger common hepatic duct, from where the secret enters the gallbladder.

How does the gallbladder work, and what factors affect its activity? During periods when digestion is not required, the bladder is in a relaxed state. The work of the gallbladder at this time is to accumulate a secret. Eating provokes the launch of many reflexes. The pear-shaped organ is also included in the process, which makes it mobile due to the beginning contractions. By this point, it already contains processed bile.

The required amount of bile is released into the common bile duct. Through this channel, the liquid enters the intestine and promotes digestion. Its function is to break down fats through its constituent acids. In addition, the processing of food with bile leads to the activation of enzymes required for digestion. These include:

  • lipase;
  • aminolase;
  • trypsin.

Bile appears in the liver. Passing through the choleretic channel, it changes its color, structure and decreases in quantity. Those. bile is formed in the bladder, which is different from the liver secretion.

The concentration of incoming bile from the liver occurs by removing water and electrolytes from it.

The principle of the gallbladder is described in the following paragraphs:

  1. Collection of bile produced by the liver.
  2. Condensation and storage of a secret.
  3. The direction of the liquid through the duct into the intestine, where food is processed and broken down.

The organ begins to work, and its valves open only after the person receives food. The gallbladder meridian, on the contrary, is activated only in the late evening from 11 am to 1 am.

Diagnostics of the bile ducts

Failure of the biliary system occurs most often due to the formation of any obstacle in the channels. The reason for this may be:

  • cholelithiasis
  • tumors;
  • inflammation of the bladder or bile ducts;
  • strictures and scars that can affect the common bile duct.

Identification of diseases occurs with the help of a medical examination of the patient and palpation of the right hypochondrium, which allows you to establish a deviation from the norm in the size of the gallbladder, laboratory tests of blood and feces, as well as using hardware diagnostics:

Ultrasonography shows the presence of stones and how many have formed in the ducts.

  1. X-ray. Not able to give specifics about the pathology, but helps to confirm the presence of a suspected pathology.
  2. ultrasound. Ultrasonography shows the presence of stones and how many have formed in the ducts.
  3. ERCP (endoscopic retrograde cholangiopancreatography). Combines X-ray and endoscopic examination and is the most effective method studies of diseases of the biliary system.
  4. CT. With cholelithiasis, this study helps to clarify some details that cannot be determined with ultrasound.
  5. MRI. Similar to CT method.

In addition to these studies, a minimally invasive method for detecting blockage of the choleretic ducts, laparoscopy, can be used.

Causes of diseases of the bile ducts

Violations in the functioning of the bladder have various causes and can be triggered by:

Any pathological changes ducts interfere with the normal flow of bile. Expansion, narrowing of the bile ducts, thickening of the walls of the common bile duct, the appearance of various formations in the canals indicates the development of diseases.

The narrowing of the lumen of the bile ducts disrupts the return flow of secretions to the duodenum. The causes of diseases in this case can be:

  • mechanical trauma caused during surgery;
  • obesity;
  • inflammatory processes;
  • the appearance of cancerous tumors and liver metastases.

Strictures formed in the bile ducts provoke cholestasis, pain in the right hypochondrium, jaundice, intoxication, and fever. The narrowing of the bile ducts leads to the fact that the walls of the channels begin to thicken, and the area above - to expand. Blockage of the ducts leads to stagnation of bile. It becomes thicker, creating ideal conditions for the development of infections, so the appearance of strictures often precedes the development of additional diseases.

The expansion of the intrahepatic bile ducts occurs due to:

Changes in the bile ducts accompany the symptoms:

  • nausea;
  • gagging;
  • soreness right side abdomen
  • fever;
  • jaundice;
  • rumbling in the gallbladder;
  • flatulence.

All this indicates that the biliary system is not working properly. There are some of the most common diseases:

  1. ZhKB. The formation of stones is possible not only in the bladder, but also in the ducts. In many cases, the patient does not experience any discomfort for a long time. Therefore, stones may go unnoticed for several years and continue to grow. If the stones block the bile ducts or injure the walls of the canal, then the developing inflammatory process is difficult to ignore. Pain, heat, nausea and vomiting will not allow this to be done.
  2. Dyskinesia. This disease is characterized by a decrease in the motor function of the bile ducts. Violation of the flow of bile occurs due to changes in pressure in various areas of the channels. This disease can develop independently, as well as accompany other pathologies of the gallbladder and its ducts. A similar process causes pain in the right hypochondrium and heaviness that occurs a couple of hours after eating.
  3. Cholangitis. It is usually caused by acute cholecystitis, but the inflammatory process can also occur on its own. Symptoms of cholangitis include: fever, excessive sweating, pain in the right side, nausea and vomiting, jaundice develops.
  4. Acute cholecystitis. inflammation has infectious nature and proceeds with pain and fever. At the same time, the size of the gallbladder increases, and deterioration occurs after eating fatty, heavy meals and alcoholic beverages.
  5. Cancer tumors of channels. The disease often affects the intrahepatic bile ducts or pathways at the gates of the liver. With cholangiocarcinoma, yellowing of the skin, itching in the liver, fever, nausea, and other symptoms appear.

In addition to acquired diseases, congenital developmental anomalies, such as aplasia or hypoplasia of the gallbladder, can complicate the work of the bladder.

Anomalies of the gallbladder

Anomaly in the development of the gallbladder ducts is diagnosed in almost 20% of people. Much less often you can find a complete absence of channels designed to remove bile. Congenital malformations entail disruption of the biliary system and digestive processes. Most congenital malformations do not pose a serious threat and can be treated; severe forms of pathologies are extremely rare.

Anomalies of the ducts include the following pathologies:

  • the appearance of diverticula on the walls of the channels;
  • cystic lesions of the ducts;
  • the presence of kinks and partitions in the channels;
  • hypoplasia and atresia of the biliary tract.

According to their characteristics, anomalies of the bubble itself are conditionally divided into groups depending on:

  • localization of the gall;
  • changes in the structure of the body;
  • deviations in form;
  • quantities.

An organ may be formed but not in its normal position and placed:

  • in the right place, but across;
  • inside the liver;
  • under the left hepatic lobe;
  • in the left hypochondrium.

Pathology is accompanied by violations of bladder contractions. The organ is more susceptible to inflammatory processes and the formation of stones.

The "wandering" bubble can occupy various positions:

  • inside the abdominal region, but almost not in contact with the liver and covered with abdominal tissues;
  • completely separated from the liver and communicating with it through a long mesentery;
  • with a complete lack of fixation, which increases the likelihood of kinks and twisting (lack of surgical intervention leads to the death of the patient).

It is extremely rare for doctors to diagnose a newborn with a congenital absence of the gallbladder. Gallbladder agenesis can take several forms:

  1. Complete absence of the organ and extrahepatic bile ducts.
  2. Aplasia, in which, as a result of underdevelopment of the organ, there is only a small, incapable of functioning process and full-fledged ducts.
  3. Hypoplasia of the bladder. The diagnosis suggests that the organ is present and able to function, but some of its tissues or areas are not fully formed in the child in the prenatal period.

Functional kinks go away on their own, while true ones require medical intervention.

Agenesis in almost half of the cases leads to the formation of stones and the expansion of the large bile duct.

An abnormal, non-pear-shaped form of the gallbladder appears due to constrictions, kinks in the neck or body of the organ. If the bubble, which should be pear-shaped, resembles a snail, then a kink has occurred that violated the longitudinal axis. The gallbladder collapses to the duodenum, and adhesions form at the point of contact. Functional excesses pass on their own, and the true ones require medical intervention.

If the pear-shaped shape changes due to constrictions, then the vesical body narrows in places or completely. With such deviations, stagnation of bile occurs, provoking the appearance of calculi and accompanied by severe pain.

In addition to these shapes, the pouch may resemble the Latin S, a ball, or a boomerang.

A bifurcation of the gallbladder weakens the organ and leads to dropsy, calculi and inflammation of the tissues. The gallbladder may be:

  • multi-chamber, while the bottom of the organ is partially or completely separated from its body;
  • bilobed, when two separate lobules join one bladder neck;
  • ductular, two bladders with their ducts function simultaneously;
  • triplication, three organs united by a serous membrane.

How are bile ducts treated?

In the treatment of blockage of the ducts, two methods are used:

  • conservative;
  • operational.

The main in this case is surgical intervention, and conservative means are used as auxiliary.

Sometimes, a calculus or a mucous clot can leave the duct on its own, but this does not mean that the problem has been completely eliminated. The disease in the absence of treatment will return, so it is necessary to deal with the cause of the appearance of such stagnation.

In severe cases, the patient is not operated on, but his condition is stabilized, and only after that the day of the operation is appointed. To stabilize the condition, patients are prescribed:

  • starvation;
  • installation of a nasogastric tube;
  • antibacterial drugs in the form of antibiotics with a wide spectrum of action;
  • droppers with electrolytes, protein preparations, fresh frozen plasma and others, mainly for detoxification of the body;
  • antispasmodic drugs;
  • vitamin remedies.

To accelerate the outflow of bile, non-invasive methods are resorted to:

  • extraction of calculi with a probe, followed by drainage of channels;
  • percutaneous puncture of the bladder;
  • cholecystostomy;
  • choledochostomy;
  • percutaneous hepatic drainage.

Normalization of the patient's condition allows the use of surgical methods of treatment: laparotomy, when the abdominal cavity is fully opened or laparoscopy performed using an endoscope.

In the presence of strictures, endoscopic treatment allows you to expand the narrowed ducts, insert a stent and ensure that the channels are provided with a normal lumen of the ducts. Also, the operation allows you to remove cysts and cancerous tumors usually affecting the common hepatic duct. This method is less traumatic and allows even cholecystectomy. Opening the abdominal cavity is resorted to only in cases where laparoscopy does not allow for the necessary manipulations.

Congenital malformations, as a rule, do not require treatment, but if the gallbladder is deformed or omitted due to some kind of injury, what should I do? Displacement of an organ while maintaining its performance does not worsen health, but with the appearance of pain and other symptoms, it is necessary:

  • observe bed rest;
  • drink enough liquid (preferably without gas);
  • adhere to a diet and foods approved by the doctor, cook correctly;
  • take antibiotics, antispasmodics and analgesics, as well as vitamin supplements and choleretic drugs;
  • attend physiotherapy, do physiotherapy exercises and massage for relief.

Despite the fact that the organs of the biliary system have relatively small size they are doing a great job. Therefore, it is necessary to monitor their condition and consult a doctor when the first symptoms of diseases appear, especially if there are any congenital anomalies.

Video

What to do if a stone appears in the gallbladder.

Source: liver.org

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Anatomy and physiology of the gallbladder

Anatomy and physiology of the gallbladder

gallbladder (vesica fellea) is a fairly thin-walled hollow muscular organ of the digestive system, in which bile accumulates, its concentration increases, and from which bile periodically (during meals) enters the common bile duct and the duodenum. In addition, the gallbladder, as part of the biliary system, regulates and maintains required level bile pressure in biliary tract.

The gallbladder is located on the lower surface of the liver in the corresponding fossa (fossa of the gallbladder). Usually it has a pear-shaped, less often conical shape. In people of tall, fragile physique with thin bones (in asthenics), the shape of the gallbladder is more often oblong, elongated or spindle-shaped, in people of short stature, strong build with a wide bone (in picnics) - bag-shaped, rounded. The length of the gallbladder ranges from 5–14 cm, averaging 6–10 cm, its width reaches 2.5–4 cm, and its capacity is 30–70 ml. However, the wall of the gallbladder is easily extensible, it can hold up to 200 ml of fluid.

In the gallbladder, the following anatomical parts are distinguished: the bottom - the widest part, the body and neck - the narrowed part. The gallbladder has two walls: the upper wall is adjacent to the lower surface of the liver, the lower wall is freer, it can come into contact with the stomach and duodenum.

After eating, the gallbladder in the bottom and body begins to contract, and its neck expands at this time. Then the entire gallbladder contracts, pressure rises in it and a portion of bile is ejected into the common bile duct.

The duration of the contraction of the gallbladder depends on the amount of fat in the food - the more fat the food contains, the longer the bladder will be in a reduced state. Of the daily food products, egg yolks, animal fats and vegetable oils. The gallbladder in men is emptied faster than in women; it also empties faster in people over 50 than in younger people. The period of bile ejection is replaced by the period of filling its bladder. The release of bile during the day is associated with food intake. At night, the bladder fills with bile. Normally, during digestion, the gallbladder makes vigorous rhythmic and tonic contractions, but in pathology, dyskinesia develops (from Latin dis - “not”, and from Greek kinema - “movement”) - inconsistent, untimely, insufficient or excessive contraction of the gallbladder. Dyskinesia can occur in two variants (types): hyperkinetic (from the Greek hyper - “above, above”) and hypokinetic (from the Greek hypo - “under, below, below”), i.e. movements may be excessive (hyper ) or insufficient (hypo).

Bile is produced continuously by the liver cells. Outside of digestion, hepatic bile enters the gallbladder and is concentrated (condensed) there. During a meal, the gallbladder is emptied and remains in a reduced state for 30-45 minutes. During this period, water and electrolytes enter its lumen, the gallbladder is thus, as it were, washed out, freed from excess particles accumulated in it.

Bile is a yellowish-brown liquid secretion produced by the liver cells. Under normal conditions, the amount of bile produced by the liver per day can reach 1.5 thousand - 2 thousand ml. Bile has a rather complex composition, it contains bile acids, phospholipids (lipids - fats), bilirubin, cholesterol and other components and plays an important role in the physicochemical processing of food and, above all, in the digestion and absorption of fat.

The formation and secretion of bile performs two important functions in the body:

- digestive - components of bile (primarily bile acids) are vital for the digestion and absorption of dietary fat;

- excretion of toxic substances from the body that cannot be neutralized by processing and are not excreted by the kidneys.

As part of bile, various harmful compounds, including medicinal ones, can be removed from the body.

Dyskinesia of the gallbladder and biliary tract

Dyskinesia of the gallbladder and biliary tract is a functional pathological disorder of the motility and tone of this organ and its ducts, causing inadequate flow of bile from the bladder into the duodenum, which leads to indigestion.

Biliary dyskinesia accounts for one eighth of all gallbladder diseases and can occur in both adults and children. Representatives of the weaker sex suffer from it ten times more often than men, which is due to the peculiarities of metabolic and hormonal processes occurring in female body. Young women of asthenic physique and adolescents are especially susceptible to this pathology. Timely treatment of biliary dyskinesia and proper nutrition provide a favorable prognosis for the disease, which does not shorten the patient's life.

Gall Bladder: Anatomy and Physiology

The gallbladder is a hollow organ located below the last rib on the right. Its length varies from 50 to 140 mm, width - from 30 to 50 mm. The volume of the gallbladder on an empty stomach can range from 30 to 80 ml, however, its capacity increases dramatically with bile stasis.

The gallbladder, which has an elongated shape, consists of a body, bottom and neck, from which the cystic duct departs. The latter, connecting with the hepatic duct, subsequently forms a common bile duct with it, which, in turn, opens into the cavity duodenum in the region of Vater's nipple, surrounded by the sphincter of Oddi.

  • a mucous membrane formed from mucus-producing epithelial and glandular cells;
  • muscular membrane, formed mainly from located circularly smooth muscle fibers;
  • connective tissue membrane that covers the gallbladder from the outside and contains blood vessels.

Among the main tasks performed by the gallbladder:

  • accumulation, concentration and storage of bile produced by the liver;
  • secretion of bile as needed into the lumen of the duodenum.

The process of excretion of bile

The complex mechanism of bile secretion, in which the gallbladder contracts with simultaneous relaxation of the sphincter of Oddi, is regulated by:

  1. Sympathetic and parasympathetic divisions of the autonomic nervous system.
  2. Intestinal hormones produced in the gastrointestinal tract during meals:
    • glucagon;
    • secretin;
    • gastrin;
    • cholecystokinin-pancreozymin;
    • motilin;
  3. Neuropeptides, which are a special kind of protein molecule that has the qualities of hormones:
    • a vasointestinal polypeptide;
    • neurotensin and others.

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As a result of the tight interaction of all these components, the gallbladder muscles contract 2 times during meals, which leads to a significant increase in pressure in the organ. The sphincter of Lutkens-Martynov relaxes, bile sequentially enters the cystic and common bile ducts, and, finally, into the duodenum through the sphincter of Oddi.

With inconsistency in the work of both parts of the nervous autonomic system, changes in the doses of hormones and neuropeptides, or the occurrence of any other pathologies, this scheme is violated.

Bile plays a very important role in the process of digestion. She:

  • increases appetite;
  • creates the necessary conditions in the duodenum for the loss of pepsin - the main enzyme of gastric juice - of its qualities;
  • takes part in the absorption of fat-soluble vitamins D, E, A and the breakdown of lipids, contributing to their absorption;
  • activates the enzymes necessary for protein digestion;
  • promotes the reproduction of the epithelium of the intestinal mucosa;
  • stimulates the production of intestinal hormones and secretion of mucus;
  • improves motility of the small intestine;
  • has an antibacterial effect.

Causes of the disease

Depending on the time of occurrence and the causes that caused the disease, it is customary in medicine to distinguish between both primary and secondary dyskinesia of the gallbladder and excretory tract.

Primary dyskinesia at the onset of the disease is only functional disorders that are not detected by such research methods as x-rays or ultrasound, and are associated with congenital malformations of the bile excretory tract. As the disease progresses, structural changes develop not only in the gallbladder itself, but also in its ducts.

Among the most common causes of primary JVP are:

  1. psychosomatic illnesses and nervous stress leading to an imbalance in the parts of the nervous autonomic system.
  2. Eating disorders and dietary errors, including:
    • binge eating;
    • irregular eating;
    • fast food;
    • insufficient chewing of food;
    • the use of low-quality and fatty foods;
  3. Lack of a mobile lifestyle, insufficient body weight, congenital muscle weakness.
  4. Allergic diseases:
    • food allergy;
    • chronic urticaria;
    • bronchial asthma;
  5. Hereditary predisposition, suggesting the likelihood of developing a disease in a child if its parents have it.

Secondary dyskinesia of the gallbladder and excretory tract is a noticeable change in the research methods that occur against the background of already developed conditions or diseases.

The most common causes of secondary JVP are:

  1. Diseases of the biliary system:
    • cholecystitis;
    • cholangitis;
    • cholelithiasis;
    • hepatitis;
  2. Diseases of the digestive system:
    • atrophy of the gastrointestinal mucosa;
    • duodenal ulcer and stomach;
    • enteritis;
    • colitis;
    • duodenitis;
    • gastritis;
  3. Chronic inflammatory processes occurring in the organs of the peritoneum and small pelvis:
    • solarite;
    • pyelonephritis;
    • ovarian cyst;
    • adnexitis;
  4. Worm infestations:
    • opisthorchiasis;
    • giardiasis;
  5. Congenital underdevelopment of the gallbladder and bile ducts.
  6. Endocrine disorders and diseases:
    • lack of estrogen or testosterone;
    • hypothyroidism;
    • obesity.

Types of dyskinesia of the gallbladder

Depending on the contractility of the walls of this organ and the excretory tract, such forms of the disease are distinguished as:

  • Hypertensive (hypermotor) dyskinesia, which develops with an increased tone of the gallbladder and bile ducts. Diagnosed in patients with a predominance of parasympathetic dominance at night nervous system enhancing tone and motor function gallbladder and its excretory ducts. Most often it can occur in young people - both in a teenager and in a child.
  • Hypotonic, or hypomotor biliary dyskinesia, which develops with a low tone of the gallbladder and excretory tract. It is diagnosed mainly in patients over the age of 40 with a predominance of the tone of the sympathetic nervous system, which is normally dominant during the day.
  • Hyperkinetic biliary dyskinesia - with active outflow of bile.
  • Hypokinetic dyskinesia. With biliary dyskinesia of the hypokinetic type, the outflow of bile occurs slowly.

Symptoms of JVP

The signs of the disease depend on the type of motor activity disorder not only of the gallbladder, but also of the excretory ducts.

The development of a disease such as hypomotor dyskinesia of the gallbladder can be indicated by various symptoms and manifestations, including:

  1. Constant aching pain on the right in the hypochondrium without a clear localization, as a rule, aggravated after eating.
  2. Belching after and between meals.
  3. Nausea and possible vomiting with an admixture of bile, the provoking factor of which is malnutrition.
  4. Bitterness in the mouth, felt mainly after intense physical exertion, eating and in the morning.
  5. Bloating and flatulence that accompany pain.
  6. Diarrhea or constipation.
  7. Decreased appetite associated with a deficiency in the flow of bile.
  8. Obesity that develops with a long course of the disease.
  9. Symptoms of dysfunction of the nervous autonomic system, including:
    • sweating;
    • increased salivation;
    • redness of the skin of the face;
    • low blood pressure;
    • decrease in heart rate.

Symptoms that may indicate the development of hypertensive biliary dyskinesia:

  1. Acute intense pain in the right hypochondrium, sometimes radiating to the heart, which can be provoked physical exercise, emotional tension or stress, as well as malnutrition.
  2. Decreased appetite.
  3. Decrease in body weight.
  4. Nausea and possible vomiting, often accompanying an attack of biliary colic.
  5. Diarrhea after eating or during an attack.
  6. Signs of abnormal functioning of the autonomic nervous system, including:
    • high blood pressure;
    • headaches;
    • general physical weakness;
    • cardiopalmus;
    • sweating;
    • sleep disorders;
    • fast fatiguability;
    • irritability.

Signs inherent in both forms of biliary dyskinesia and gallbladder:

  • yellowness of the whites of the eyes and skin;
  • plaque on the tongue with a yellowish or whitish tint;
  • dulling of sensations of taste;
  • dark urine and colorless feces.

The mixed form is characterized by symptoms of two types of biliary dyskinesia in varying degrees of severity.

Diagnostics

Diagnosis of biliary dyskinesia, which focuses on determining the type of JVP and identifying associated diseases, usually includes:

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With hypotenic dyskinesia:

  • choleretics that enhance the production and separation of bile (Holenzim, Allochol, Holiver);
  • tonic drugs that correct the functioning of the autonomic nervous system (ginseng tincture, eleutherococcus extract);
  • tubeless tubes prescribed to improve the outflow of bile from the gallbladder and bile ducts only outside the period of exacerbation (magnesium sulfate, Sorbitol, Xylitol);

With hypertensive dyskinesia:

  • cholekinetics that increase the tone of the gallbladder with a simultaneous decrease in the tone of the bile ducts (oxafenamide, hepabene);
  • antispasmodics used to relax the tone of the sphincters, which helps relieve pain (Gimekromon, No-shpa, Drotaverine, Papaverine, Promedol);
  • sedatives that correct the work of the autonomic nervous system (potassium bromide, sodium bromide, tincture of valerian or motherwort).

Treatment with mineral waters

With hypomotor dyskinesia - waters of high mineralization (Essentuki No. 17, Arzani). With hypermotor dyskinesia - waters of low mineralization (Essentuki No. 4 or 2, Narzan, Slavyanovskaya).

Physiotherapy

With biliary dyskinesia of the hypotonic type:

  • electrophoresis with pilocarpine;
  • amplipulse therapy.

For hypertensive variant:

  • electrophoresis with papaverine and platifilin;
  • laser therapy.

In addition, the doctor may prescribe:

  1. Hirudotherapy, or treatment with leeches, with an effect on the biologically active points of the pancreas, liver and gallbladder;
  2. Acupuncture, or acupuncture, which affects the body by inserting special needles into special points on the body;
  3. Massage, especially acupressure, affecting the normalization of the activity of the gallbladder;
  4. Diet food.

If necessary, therapy is carried out for diseases that led to the development of biliary dyskinesia. Among them are various infections, peptic ulcer, helminthic invasion, cholelithiasis.

Effective treatment of dyskinesia of the gallbladder and excretory tract is impossible without observing the correct regime of work and rest.

In a patient with this pathology, the following should become the norm:

  • going to bed no later than 11 pm:
  • full sleep for at least eight hours a day;
  • proper nutrition;
  • alternation of physical and mental activity;
  • regular walks in the fresh air.

In addition, with JVP, sanatorium treatment in sanatoriums specializing in diseases of the digestive system will be useful.

Some patients try to get by folk remedies and herbs are used to treat biliary dyskinesia. Many experts consider such therapies questionable, therefore, in order not to harm yourself, you should consult a doctor before taking any traditional medicine.

Successful treatment of dyskinesia of the gallbladder and excretory tract is impossible without diet, which is prescribed for a rather long time - from 3 to 12 months. Its purpose is sparing nutrition and normalization of the functions of the liver, biliary tract, and organs of the digestive system.

A diet for gallbladder dyskinesia of any type involves proper nutrition with the exclusion from the diet of foods such as:

  1. Spicy, sour, salty, fatty, fried and smoked foods;
  2. Alcoholic drinks;
  3. Rich broths;
  4. Garlic, onion, seasonings and spices;
  5. Sorrel and radish;
  6. Fatty varieties of fish, meat;
  7. Whole milk and cream;
  8. Canned food and marinades;
  9. Products that increase gas formation - Rye bread and legumes;
  10. Cocoa, black coffee, and carbonated drinks;
  11. Chocolate;
  12. Baking and confectionery with cream.

Meals should be fractional, at least 5-6 times a day, portions should be small. In the first days after an exacerbation, the products should be consumed in a liquid, pureed or minced form, later, when acute symptoms dyskinesia of the biliary tract and gallbladder will disappear - in boiled, baked or steamed. It is recommended to reduce salt intake to 3 g per day to reduce fluid retention in the body.

Products allowed for consumption:

  • soups with vegetable broth;
  • low-fat varieties of poultry, meat and fish;
  • pasta;
  • any cereals;
  • boiled egg yolk;
  • butter and vegetable fats;
  • lactic acid products;
  • yesterday's bread;
  • vegetables in any form;
  • honey, marshmallow, marmalade, caramel;
  • non-acid fruits and berries;
  • vegetable and fruit juices.

With hypermotor biliary dyskinesia, the following should be excluded from this list:

  • fresh vegetables, berries and fruits;
  • veal and pork;
  • egg yolk;
  • sugar and caramel.

Prevention of biliary dyskinesia also lies in proper nutrition.

Dyskinesia in children

The child's periodic complaints of abdominal pain, loss of appetite and stool disorder may indicate the development of such a pathological process in the biliary tract as gallbladder dyskinesia.

Dyskinesia in a child is a complex disorder of the gastrointestinal tract, which is often observed at an early age. Symptoms of the disease do not appear immediately, but as a result of prolonged progression. At the first signs of pathology in a child, parents need to seek help from specialists, in no case self-medicating. Only an experienced doctor will be able, after examination and anamnesis, based on the results of laboratory tests and diagnostic examination, to make a diagnosis and begin effective therapy.

Treatment, which, depending on the stage of the disease and the condition of the child, is carried out on an outpatient or inpatient basis, involves the use of drug therapy to eliminate the symptoms and causes of biliary dyskinesia. In doing so, special attention should be paid to general state baby and eliminate unnecessary stress. A special diet, selected individually, will not only improve the general condition of a sick child, but will nullify all pain symptoms.

It is no secret that the treatment of biliary dyskinesia in children takes a long time and requires great efforts of both the doctor and the child and his parents. With full and timely assistance, you can easily cope with the disease, however, to be successful, you should stock up on willpower and patience. With conscientious implementation of the recommendations of the attending physician and diet, a positive result will not be long in coming - the prognosis will be favorable, and the child will be able to lead a healthy and fulfilling life in the future.

O.A. Sablin, V.B. Grinevich, Yu.P. Uspensky, V.A. Ratnikov

Bile is an indispensable participant in the process of food hydrolysis, acts as a regulatory unit in the mechanisms of regulation of the functions of the stomach and intestines, the content of enzymes and hydrochloric acid in gastric juice. Bile also has digestive functions: excretions are excreted with it, it participates in interstitial metabolism. The synthesis of bile proceeds continuously. It enters the bile ducts under a pressure of 240-300 mm of water. Art. The liver secretes about 500-2000 ml of bile per day. Bile secretion is performed by parenchymal cells of the liver (75% of its acid-dependent and acid-independent fraction), epithelial cells of the bile ducts (25%). The ductal fraction of bile is formed by epithelial cells, which enrich the fluid with bicarbonates and chlorine simultaneously with the reabsorption of water and electrolytes from canalicular bile.

The formation of bile is due to transport from the blood plasma, diffusion through the sinusoidal membrane into the hepatocyte of water, ions, secretion of bile acids by hepatocytes. It is provided by Na-independent active process, the energy of aerobic respiration of substrates, which are formed during glycolysis of carbohydrates, oxidation of lipids and blood lactic acid. In the mitochondria of hepatocytes and outside of them, bile acids are formed from cholesterol with the participation of ATP. Hydroxylation during the formation of cholic acid is carried out in the endoplasmic reticulum of the hepatocyte. Recently, the ion transport system has been of great importance in the synthesis of bile acids.

It should be recalled that in the composition of the bile secreted into the intestine, newly synthesized bile acids do not exceed 10%, the rest of the pool of acids is a product of the enterohepatic circulation of bile acids from the intestine to the blood and to the liver. The main energy expended by the hepatocyte is used to transport acids and bile across its plasma membrane by the Na-dependent or Na-coupled (taurocholate) transport system. The precursor of bile acids is lipoprotein cholesterol. Almost all (90%) bile acids are nothing but hydroxyl derivatives of 5-cholanic acid.

Cholic, chenodeoxycholic and lithocholic acids are synthesized in the liver. Deoxycholic acid is formed due to the activity of the intestinal microflora. Most of the bile acids in the blood are associated with albumin and blood lipoproteins. The absorption of bile acids by liver cells is carried out using a membrane protein that acts as a receptor and carrier. The number of receptors and the activity of Na + ,K + -ATPase of the cell membrane, which maintains the concentration gradient of Na + , is regulated by the bile acids themselves. Having overcome the sinusoidal membrane, bile acids move in the cytosol from the membrane region to others: either by free diffusion, or with the help of intracellular transport, or with the help of intracellular structures - by the movement of vesicles.

Most transport proteins belong to the glutathione S-transferase family. Of these, anion-binding protein ligandin and glutathione S-transferase are the main intracellular proteins of the hepatocyte that bind lithocholic acid. In the cytosol of the hepatocyte, glutathione S-transferase reduces the concentration of free bile acids, which facilitates the transmembrane transfer of bile acids from the blood to the hepatocyte. In addition, it prevents the leakage of bile acids from the hepatocyte through the sinusoidal membrane back into the blood, participates in the process of transporting bile acids from the sinusoidal membrane of the hepatocyte to the endoplasmic reticulum, and then to the Golgi apparatus.

From the Golgi apparatus to the canalicular membrane, bile acids move by directed vesicular transport. Several mechanisms of intracellular transport of bile acids have been shown: free diffusion, directed vesicular transport and specific transport proteins. Bile acids also penetrate through the canalicular membrane of the hepatocyte into the canalicular cavity in several ways, this is either a voltage-dependent process in the presence of a specific carrier - a glycoprotein transport protein with a molecular weight of 100 kDa, or it is vesicle exocytosis, and it is a Ca ++ -dependent process, or bile acids from the vesicles enter the cavity of the bile canals through microtubules and microfilaments, and then the mechanism of the contractile activity of the bile canals is important. This explains the action of cytochalasin B and cytochalasin D, which block the connection of microfilaments with the canalicular membrane or colchicine and vinblastine. The regulators of the contractile activity of the bile canals are the bile acids themselves.

The mechanism of formation of the acid-independent fraction of bile is based on the active transport of sodium into the lumen of the bile ducts by Na + , K + -ATPase of hepatocyte membranes. According to this hypothesis, Na + enters the hepatocyte through the sinusoidal membrane and carries with it chloride ions, while most of the Na + that enters the cell is sent to the blood by Na + , K + -ATPase, which entails an increase in the intracellular concentration of Cl - . In this case, the electrochemical equilibrium is disturbed. According to the electrochemical gradient, chloride ions pass through the canalicular membrane from the hepatocyte and thereby increase the flow of water and electrolytes from the liver cells into the lumen of the bile ducts. Another hypothesis is based on the leading role in the secretion of the acid-independent fraction of bile - bicarbonates, which, along the osmotic gradient, increase the flow of water and electrolytes from the liver to bile. The mechanism of secretion of HCO 3 - hepatocytes associated with the transport of protons H + -ATPase or Na + /H + exchange.

The intensity of bile formation is determined by the osmotic properties of bile proteins, the concentration of which in bile ranges from 0.5 to 50 mg/ml. There is a group of people whose bile is devoid of protein, while others, on the contrary, have bile enriched with protein. One way or another, but protein is the third of the main organic components of bile. On average, a person receives about 10 g of it per day and it can be divided into 10-25 protein fractions. They, for the most part, are blood serum proteins: these are IgA and haptoglobin. Albumin and the rest is formed in the hepatocyte and epithelial cells of the bile ducts. Bile contains IgA (42%), IgG (68%), IgM (10%), but only IgG in its origin is completely a blood serum protein. The rest are partially synthesized by immunocompetent cells of the portal vein, bile ducts, and the liver itself. About 28 mg of IgA enter the bile from the blood serum per day in a person, much more, about 77 mg, are of local origin. Monomeric IgA comes almost entirely from the blood serum. The secretory component - glycoprotein is a specific protein that ensures the transfer of polymeric IgA, IgM through the epithelium in such a way that a complex is formed as part of the secretory component and immunoglobulin, and by transcytosis transfers the protein through the canalicular membrane of the hepatocyte. In humans, the source of the secretory component of bile is the epithelial cells of the bile ducts.

Bile proteins are represented by enzymes of plasma membranes and lysosomes, and even pancreatic amylase. Of these, one can point to 5-nucleotidase, alkaline phosphatase, alkaline phosphodiesterase, L-leucyl-b-naphthylaminase, Mg-ATPase, b-glucuronidase, galactosidase, N-acetyl-b-glucosaminase. Bile proteins perform one of the important functions, being a compound capable of regulating the secretion of that part of bile that does not depend on bile acids due to its osmotic properties (albumin). They catalyze the conversion of water-soluble bilirubin - diglucuronide in bile into a water-insoluble form of unconjugated bilirubin, thereby contributing to the formation of pigment stones. Apoproteins A-I and A-II slow down or even prevent the formation of cholesterol nuclei and cholesterol crystals. Apo-B in human bile plays an important role in the transport of cholesterol.

It is known that the intensity of some metabolic reactions and, importantly, the synthesis of acid-dependent and acid-independent bile fractions depend on protein biosynthesis in liver cells. It is assumed that one of probable causes The development of intrahepatic cholestasis is a violation of protein biosynthesis in hepatocytes, which, in medical practice, can be caused by the use of antibiotics. Receptors for vasopressin, glucagon, insulin, norepinephrine are installed on the plasma membrane of the hepatocyte.

Bile secretion. The intralobular and interlobular bile ducts unite, merging to the hepatic ducts (Fig. 13). Here, outside the liver, there is one of the sphincters of the bile ducts - sphincter Mirizzi (Mirizzi). The common bile duct pierces the wall of the duodenum, ending in a complex formation - the large duodenal papilla (Fateri papilla), which has a common tank for pancreatic secretion and bile. Three sphincters are distinguished in the major duodenal papilla: the duct itself (Aschoff), the sphincter of the nipple of Boyden (Boyden) and the sphincter of the pancreatic duct, all united under the name sphincter of Oddi (Oddi).

The cystic duct connects the gallbladder to the hepatic duct. The gallbladder cavity is a reservoir of hepatic bile, its wall has several layers of smooth muscles and is capable of contraction. In it, an intensive process of water absorption and excretion of mucin into the bile as part of the secretion of the mucous glands takes place. The concentration function of the gallbladder is carried out in the parietal layer of mucus. Due to this, more concentrated bile flows around the walls, sinks to the bottom of the bladder, while the core in the center contains less concentrated bile. The filling of the gallbladder after its emptying in response to food stimulation and the achievement of relative homogeneity of its contents occurs no faster than after 120-180 minutes.

Even outside of digestion, due to rhythmic fluctuations in the tone of the sphincters of the large duodenal papilla, changes in intracavitary pressure in the duodenum and the presence of a certain tone of the gallbladder, hepatic bile can enter the duodenum in small quantities. It is known that hepatic bile, even during digestion, manages to reach the neck of the gallbladder for a short moment and, spreading along its walls, changes the concentration of bile in the bladder.

The gallbladder performs a reservoir role not only between digestion, but also has a reservoir function during digestion.

The regulation of the motor activity of the terminal section of the common bile duct is provided by the following factors:

  1. Pressure in the common bile duct. With an increase in pressure, the amount of bile passing through the duct increases. There is an elongation of the opening phase of the sphincter due to the phase of its closing.
  2. Pressure in the duodenum. The rise in intracavitary pressure in the duodenum causes spasm of the sphincter of Oddi. A decrease in bowel pressure, caused, for example, by aspiration through a duodenal tube, increases the amount of bile flowing through the sphincter.
  3. Peristalsis of the duodenum. Under normal conditions, duodenal motility does not affect the flow of bile through the sphincter. With upward movements, a spasm of the sphincter of Oddi occurs.
  4. The contents of the duodenum. If the intestine is free and does not contain chyme, the rhythmic activity of the sphincter is negligible, and only a small amount of bile passes through it. The release of food from the stomach into the intestine causes a rapid change in the activity of the sphincter: the first reaction is a spasm of the sphincter of Oddi, probably caused by a rise in pressure in the intestine. This spasm does not depend on the type of food, its duration is 4-10 seconds, sometimes up to 30 minutes. The increase in the duration of this spasm is clearly pathological. This reaction is strongest after the infusion of hydrochloric acid into the duodenum. After a temporary spasm, the sphincter opens again, due to a decrease in its tone, caused to a large extent by the type of food. Fat, olive oil, magnesium sulfate have the most effective effect on the sphincter. Carbohydrates have the least effect. The decrease in tone is probably due to the action of chemicals on the duodenal mucosa, a local reflex, and is not due to the effect of cholecystokinin-pancreazimin on the contraction of the gallbladder.

Under experimental conditions, the coordination of the motor activity of the stomach, gallbladder and sphincter apparatus of the biliary system has been proven. Electrophysiologically, it has been established that the appearance of peak potentials (it is believed that they cause contractions) on the electrograms of the duodenum, gallbladder, Lutkens sphincter is synchronous with the appearance of peak potentials on the electrogram of the stomach. The electrical activity of the sphincter of Lutkens and the gallbladder have a peculiar cycle, where an increase in fast (peak potentials) activity occurs after three cycles to the fourth, synchronously with the peristalsis of the stomach. Also, rises and falls of intracavitary pressure in the gallbladder alternate. In the interval between the periodic occurrence of peak potentials of the stomach, there are no peak potentials of the duodenum. A few seconds before the contraction of the antrum of the stomach, the initial section of the duodenum relaxes. This corresponds to the maximum intracavitary pressure of the gallbladder and the beginning of relaxation of its walls after the release of a portion of bile into the intestine. Almost simultaneously with the contraction of the antrum of the stomach, potentials arise on the muscles of the duodenum. At the same time, the maximum amplitude of the intracavitary pressure of the gallbladder is observed, which is explained by the closure of its sphincters and the cessation of the release of bile into the intestine.

Functional connections between the stomach, duodenum and biliary apparatus are not limited only to the relationship in the motor-evacuation activity of these organs. They are also observed at rest.

The role of bile in digestion. Bile entering the duodenum mixes with the chyme that has left the stomach when the pH of the intestinal contents reaches the optimum level for the activity of pancreatic and intestinal enzymes. It promotes the hydrolysis of proteins, carbohydrates, and also emulsifies fats.

Cholecystitis- one of the most common diseases of the digestive system, second in frequency only to peptic ulcer.

Cholecystitis and cholelithiasis affect people of any age, and women get sick 3-7 times more often than men. This is largely due to the influence of pregnancy.

Chronic cholecystitis- chronic recurrent inflammation of the gallbladder caused by various microorganisms Hematogenous, lymphogenous and contact (from the intestine) ways of spreading the infection are possible.

Our experience in monitoring and treating pregnant women with chronic cholecystitis has shown that the clinical picture of the disease during pregnancy is similar to that in non-pregnant women. The most common symptom that occurs during exacerbation of chronic cholecystitis is pain (92.9%). In such cases, patients are concerned about dull, aching (or acute, depending on the type of concomitant dyskinetic disorders of the biliary tract) pain, a feeling of heaviness (in 67.9% of patients) in the right hypochondrium. Pain radiates to the right shoulder blade, right shoulder, collarbone. In addition, nausea, vomiting, a feeling of bitterness in the mouth, and heartburn appear. Emergence or strengthening of pains, the dyskinetic phenomena after honors in a diet, in process of progressing of pregnancy is characteristic. Often the pain is aggravated in the sitting position, in 25% of pregnant women they are provoked by the movement of the fetus and depend on its position in the uterus.

An objective examination reveals zones of Zakharyin-Ged skin hyperesthesia in the right hypochondrium, under the right shoulder blade, and this symptom appears one of the first. On palpation of the abdomen, pain in the right hypochondrium is determined, positive symptoms of Kera (pain when inhaling during palpation of the right hypochondrium), Ortner (tapping the edge of the palm along the right costal arch causes pain), Murphy (pain occurs when the brush is inserted into the region of the right hypochondrium at the height of inspiration), Georgievsky - Mussi (pain at the point of the phrenic nerve between the legs of the sternocleidomastoid muscle), etc.

The diagnosis of chronic cholecystitis is established on the basis of the patient's complaints, a carefully collected anamnesis (pay attention to past infectious diseases, primarily viral hepatitis, it is important to identify attacks of acute pain in the right hypochondrium in the past, "biliary" colic); objective data and results of additional research methods are taken into account.

Indicators of clinical and biochemical analyzes blood samples in pregnant women should be evaluated with caution. For example, neutrophilic leukocytosis may be a leukemoid reaction to pregnancy, and not a consequence of an exacerbation of the inflammatory process in the gallbladder. In a biochemical blood test, in addition to possible hyperbilirubinemia and hypercholesterolemia, there are no significant changes.

One of the most important methods of laboratory diagnosis of non-calculous cholecystitis is the study of bile obtained by duodenal sounding. The latter, in the variant most commonly used in the clinic, practically does not provide objective criteria for judging the motor function of the biliary system, therefore it is more expedient to carry out multi-stage duodenal sounding. According to recent data and our own results, this method is not inferior to oral cholecystography in its informativeness, the use of which, like other radiological methods, is not indicated during pregnancy. Contraindications for probing in pregnant women are the threat of abortion, placenta previa, severe myopia (6 or more diopters). The study begins in the morning on an empty stomach. After the introduction of the duodenal probe into the duodenum, the location of the olive is determined by introducing air into the probe with a syringe. When the probe is in the stomach, the patient feels the introduction of air and its gurgling is heard, but when the olive is in the duodenum, this does not happen. During probing, 5 stages (phases) are recorded, the amount of bile is measured every 5 minutes and the duration of each phase is determined Stage I - “choledochus-phase” - the time of emptying the common bile duct In response to irritation of the walls of the duodenum continuously for 20-40 minutes golden yellow bile is secreted. Stage II - the phase of the "closed sphincter of Oddi" - the time between the end of the introduction of the cholecystokinetic agent and the appearance of bile (portion A|) lasting 3-6 minutes. As a cholecystokinetic agent, 30-40 ml of a 33% solution of magnesium sulfate is usually used. Stage III - "cystic duct phase" - the appearance of bile (portion A 2) and emptying of the cystic duct, its duration is normally 4-6 minutes, the amount of bile is 4-6 ml. Stage IV - "bubble phase" - emptying of the gallbladder, its duration is 25-30 minutes, the amount of bile is 40-60 ml (portion B). Stage V - “hepatic phase” - bile leakage from the intrahepatic tract (portion C), its duration is normal - 20-25 minutes, the amount of bile is 30-45 ml. After all 5 stages of the study, a stronger cholecystokinetic agent is again introduced through the probe - 30 ml of sunflower (or olive) oil, when bile is released, its amount is again measured. Re-introduction of the stimulus is done in order to identify residual bile and make sure that the gallbladder is completely empty during the main probing. Thus, multi-stage duodenal sounding makes it possible to detect motor function disorders in the biliary excretion system (as a rule, hypomotor dyskinesia of the gallbladder) and is the only possible method for determining the functional state of the sphincter of Oddi during pregnancy.

A biochemical study of bile is of great diagnostic value, in particular, in identifying an inflammatory process in the gallbladder, which is characterized by a decrease in the level of cholic acid, bilirubin, the cholate-cholesterol coefficient and an increase in the concentration of cholesterol. high lipid content and low concentration of bile acids and bilirubin in the obtained samples.

In recent years, the method of ultrasonic echography has attracted increasing attention. Numerous observations have shown that ultrasound diagnostics- harmless to mother and fetus, easy, highly informative and relatively simple diagnostic method Ultrasound procedure of the gallbladder helps to identify changes in the shape, size and position of bladder stones, makes it possible to trace the dynamics of the inflammatory process in it, dyskinetic disorders. During pregnancy, ultrasonic echography of the gallbladder is limited by its duration: after 33-35 weeks, the pregnant uterus may interfere with the visualization of the gallbladder.

Ultrasound cholecystography is performed in the morning, on an empty stomach, after an overnight fast, in the position of a woman on her back (or on her left side) with a raised head of the couch, at the height of a deep breath. Initially, a transverse and then a longitudinal scan is made. Transverse scanning is carried out by sequentially moving the sensor every 0.5 cm from the xiphoid process of the sternum to the direction of the navel; longitudinal scanning - at the same intervals, moving the sensor from the anterior axillary line to the right parasternal. The unchanged gallbladder has an oval elongated shape (length does not exceed 9 cm, diameter - 3 cm), evenly limited, wall thickness is not more than 0.2-0, 3 cm, the cavity is homogeneous, free from echoes. By measuring the length, width and anteroposterior dimensions of the gallbladder, it is possible to calculate its volume, which makes it possible to judge the function of the gallbladder, to trace the dynamics of changes in volume after giving a trial breakfast (two egg yolks).

With a long-term inflammatory process in the gallbladder, its deformation can occur, which we detected in 2% of patients, thickening and thickening of the wall (56% of cases), inhomogeneity of the cavity (diffuse or parietal located), infiltration of the wall and perivesical tissue, doubling the contour of the wall.

X-ray and radiocholecystography are contraindicated during pregnancy, however, in the early postpartum period they can and should be used to diagnose the presence of stones in the gallbladder, violations of its motor and concentration functions.

In our observations, it was found that exacerbation of chronic cholecystitis more often (92.9%) develops in the third trimester of pregnancy. The outcomes of the latter in most cases are not too burdened. Chronic cholecystitis is not an indication for abortion, but it should be borne in mind that the course of pregnancy in 64.1% of cases is complicated by early toxicosis, while vomiting reaches 12-15 times a day, dragging on until 16-20 weeks of pregnancy (in 23 .3% of patients). Approximately 1/3 of the patients develop hypochromic iron deficiency anemia, 12.8% develop insufficiency of the cardiac part of the stomach Late toxicosis of pregnant women (dropsy, nephropathy) was noted in 56.7% of women, cholestatic hepatosis - in 6.6% Chronic hepatitis does not have a negative effect impact on the fetus and newborn.

The principles of therapy for chronic cholecystitis during pregnancy are the same as in non-pregnant women. Dietary treatment is of leading importance: fractional nutrition (frequent, at least 5-6 times a day, eating in small portions), food should not contain irritating components (spices, pickles, smoked meats, refractory fats). The total calorie content averages 3000-3200 kcal, with a sufficient content of proteins, fats and carbohydrates. With concomitant exacerbation of chronic cholecystitis, hypo- and atonic dyskinesias of the gallbladder, the diet expands due to “cholecystokinetic” products (weak broths, cream, sour cream, soft-boiled eggs, vegetable oils). It is very important to include in food products containing lipotropic substances (cottage cheese, cod, protein omelettes).

All pregnant women suffering from chronic cholecystitis are shown the appointment of choleretic agents, among which there are a large number of herbal preparations with a mixed (choleretic and cholecystokinetic) effect. Sandy immortelle flowers, corn stigmas, rose hips, barberry root, dill seeds, peppermint leaves are prescribed as decoctions / 10-15 g of grass per 200 ml of water, brewed like tea) 1/3 cup warm for 30-40 minutes before meals 3-4 times a day. Patent remedies can also be recommended: flamin (0.5 g 4 times a day), holosas (1 tablespoon 4 times a day), etc.

With an exacerbation of the infection, it may be necessary to conduct antibiotic therapy. The most indicated is the use of oleandomycin (0.25 g 4 times a day), ampicillin (0.25 g 4 times a day) in short courses of 4-5 days. Of the sulfa drugs, it is desirable to prescribe only short-acting sulfonamides (etazol 0.5 g 4 times a day).

In the case of an attack of acute pain in the right hypochondrium, the most justified is the introduction of baralgin (orally and parenterally), which has an antispasmodic and analgesic effect. It should be noted that in the treatment of exacerbation of chronic cholecystitis during pregnancy, a number of antibiotics (streptomycin, gentamicin, tetracycline, oletethrin, morphocycline), choleretic drugs (barberine biosulfate, nikodin, olimetin), ganglioblockers (benzohexonium, dimecolin, quateron) should not be prescribed due to their possible harm to the fetus.

To combat bile stasis, it is important to use "blind" duodenal soundings with mineral water (Borzh, Essentuki), sorbitol or xylitol (10-13 g per 100 ml of water), vegetable oils (30-40 ml) 1 time in 7-10 days .

Considering that in pregnant women a significant load falls on the liver, with drug treatment chronic cholecystitis, it is necessary to introduce lipotropic substances into the complex of therapeutic factors: methionine (0.5 g 3 times a day), lipoic acid (0.025 g 3 times a day), multivitamins (gendevit 1 tablet 4 times a day).

From sedatives, decoctions of valerian root and motherwort herb, trioxazin are recommended, from tonic - pantocrine, eleutherococcus extract, ginseng root in generally accepted therapeutic doses. With the development of symptoms of insufficiency of the cardiac section of the stomach, antacids (Almagel) are prescribed.

A comprehensive examination, timely treatment and prevention can prevent the development of an inflammatory process in the gallbladder, the formation of stones in it. Pregnant women suffering from chronic cholecystitis require treatment not only during an exacerbation of the disease, but also prophylactically during remission.

During pregnancy, acute cholecystitis may develop. In such cases, the pregnant woman should be hospitalized in a surgical hospital, where the issue of surgical treatment, which is permissible during pregnancy, will be resolved while maintaining the latter.

Dyskinesia of the biliary tract- functional disorders of the motility of the gallbladder and ducts, most often complicate the course of pregnancy.

Clinically, hypomotor dyskinesia of the gallbladder is characterized by almost constant dull, aching pain in the right hypochondrium, radiating to the right shoulder blade, shoulder, collarbone, a feeling of heaviness in the right hypochondrium. For hypermotor dyskinesia, attacks of short-term acute pain in the right hypochondrium with the same irradiation are typical. Pain points and zones of skin hyperesthesia, characteristic of chronic cholecystitis (see above), are not pronounced, sometimes absent. The diagnosis is established on the basis of the clinical picture, data of multi-stage duodenal sounding, ultrasonic cholecystography.

Therapeutic measures are similar to those in the treatment of chronic cholecystitis. Biliary dyskinesia does not significantly affect the course and outcome of pregnancy.

Postcholecystectomy syndrome develops after gallbladder removal surgery, in the presence of technical defects of the operation, complications and concomitant diseases. The main manifestations are pain syndrome and cholestasis phenomena. Treatment during pregnancy is conservative. This pathology is not an indication for the prohibition or termination of pregnancy.

Gallstone disease (cholelithiasis)- a disease characterized by the prolapse of gallstones in the liver, biliary system. The most common stones are found in the gallbladder.

As our studies have shown, pregnancy contributes to the manifestation of latent gallstone disease (in 44.4% of cases); exacerbations of the disease occur more often (85.2%) in the second trimester of pregnancy.

Clinical manifestations of cholelithiasis depend on the location of the stones, their size, concomitant infection Clinical picture resembles an exacerbation of chronic cholecystitis with a predominance of attacks of acute pain in the right hypochondrium with typical irradiation. If the common bile duct is blocked by a stone, jaundice may develop, which requires differential diagnosis with viral hepatitis, cholestatic hepatosis of pregnant women. In the case of complete obstruction of the cystic duct or neck of the gallbladder with a stone, dropsy of the bladder with a characteristic symptom complex may develop.

Great opportunities for diagnosing cholelithiasis during pregnancy have opened up in connection with the widespread introduction of the ultrasound method into clinical practice. With ultrasound cholecystography, it became possible to identify stones in the gallbladder and bile ducts, which are structures of various sizes, followed by an ultrasound shadow (the stone, being an echo-dense structure, completely reflects ultrasound waves, and images of the underlying tissues are not obtained). An important feature of calculi is their ability to move to the lower part of the gallbladder with a change in body position or a deep breath. Ultrasound examination makes it possible to identify stones 0.2-0.3 cm in size, while the accuracy of the method approaches 100% [Demidov V. N et al., 1984; Rubaltelli L. et al, 1984].

In the early postpartum period, the use of x-ray oral cholecystography is justified. Conservative treatment of gallstone disease aims to reduce the inflammatory process in the gallbladder, improve the outflow of bile and the motor function of the gallbladder and ducts. In many ways, the treatment of cholelithiasis is similar to the treatment of chronic cholecystitis, however, in case of cholelithiasis, the intake of choleretic agents from the group of cholecystokinetics (vegetable oils, magnesium sulfate, etc.) must be sharply limited.

In case of blockage of the common bile duct with a stone, if it is not possible to restore the outflow of bile within a week, surgical treatment is indicated, which can be carried out in the early stages of pregnancy with its preservation. At the end of pregnancy, the question of preliminary delivery of a woman with subsequent cholecystectomy is legitimate.

Pregnancy with cholelithiasis can be saved, although in cases with frequent exacerbations of the disease, long-term intractable biliary colic with jaundice in the past, patients should be advised to undergo surgical treatment before pregnancy or its termination in the early stages.

biliary system- the apparatus of the digestive system, designed to excrete into the intestines a physiologically important product produced in the liver - bile, which is involved in the digestion and absorption of fats and fat-soluble vitamins, in the suppression of putrefactive microflora in the intestines. Only in the presence of bile, fats and fat-soluble vitamins (A, E, D, K) are broken down and become able to be absorbed by the intestinal walls and absorbed by the body. Some harmful substances that a person receives from food and medicines, the liver, together with bile, secretes into the intestine for their subsequent removal from the body. The release of bile into the lumen of the duodenum in time should be coordinated with food intake. With untimely and insufficient secretion of bile, fats remain undigested and are processed by bacteria - inhabitants of the gastrointestinal tract. This leads to discomfort and pain in the abdomen, increased gas formation, stool disorders, as well as a deficiency of fat-soluble vitamins: vitamin A (due to the lack of which night blindness develops), vitamin D (its deficiency leads to brittle bones), vitamin K (its deficiency increases the risk of bleeding). An important function of bile is to remove cholesterol from the body.

From the liver cells to the duodenum, bile passes through the bile duct system, accumulating in the gallbladder. Violations of the contractions of the gallbladder and ducts impair the activity of the entire biliary system and are aggravated by inflammatory processes, the formation of gallstones. One of the main reasons for the formation of stones in the biliary tract is a metabolic disorder, in particular, cholesterol metabolism.

Interestingly, disorders in the biliary system are not always detected in a timely manner., however, there is a characteristic complex of symptoms that clearly indicates deviations:

Pain in the epigastric region and right hypochondrium. As a rule, they have a clear connection with the intake of fatty and fried foods, smoked meats (abdominal pain that occurs on an empty stomach is completely uncharacteristic of diseases of the biliary system).

In the case of gallstone disease, the appearance of pain can be provoked by shaking, driving, or sudden movements that lead to the movement of stones. In such cases, attacks of biliary colic develop - intense spastic pain. Helps relieve spasms topical application heat and the introduction of antispasmodics.

For an attack of biliary colic characterized by the appearance of "reflected pain" in the right half chest, right shoulder, right shoulder blade. Also, in diseases of the biliary system, symptoms of bloating, excessive gas, nausea, and bitterness in the mouth are common.

To prevent the development of cholelithiasis, it is very important to ensure the coordinated work of all organs of the biliary system. That's what it's made for