Postcholecistectomic syndrome symptoms and treatment of exacerbations. Postcholycistectomic syndrome: diagnosis and treatment

Diseases of the hepatobiliary system responsible for the function of digestion and output of the exchange products, conservative treatment. Only in rare cases in the formation of stones in a bustling bubble, overlapping excretory ducts, resort to surgical intervention. Postcholecistectomic syndrome (PCEC) is a state at which a disruption of the motor activity of the ring-shaped muscle and duodenum (DPK) is manifested after restraint. The pathological process is accompanied by pain and dyspepsia (dysfunction of digestion).

Causes of postcholectectomic syndrome

Pathology develops after some time after holding cholecystectomy (approximately in 15% of cases). Against the background of the removal of the body, a violation of circulation in the biliary region is developing. The gallbladder is a storage and supplier of the secret in the intestine. The consequence of insufficient supply of the digestive system becomes its dysfunction. The patient's well-being deteriorates, returns preoperative symptoms based on pain syndrome. Provice PCPs may have a number of factors:

1. Diagnostic measures carried out not fully affecting the quality of surgical intervention.
2. Damage to the vessels of withdrawing pathways that occurred during cholecystectomy, inadequate installation of drainage.
3. Insufficient development of bile acids.
4. The cause of the anomaly in is often chronic diseases of the digestive tract that impede the export of secrets into the duodenum.
5. The narrowing of the vessels in the Large PCD papilla or microbial destruction of microflora.

One of the reasons for PHES is a fragment of dense education (stone) in biliary ducts left during operation.

The launching mechanism for the development of the syndrome can serve as pathology in history:

• inflammation of the intestinal mucosa (duodenitis) or pancreas (pancreatitis);
• insufficient food promotion (discsion), Sphinteer dysfunction Oddi, gastroesophageal reflux pathology;
• dPK wall protrusion, the presence of fistula (fistula), ulcerative defeat;
• education of adhesions in the sanguage region, cysts in the duct, hernia diaphragm;
• irritable bowel syndrome, dysbacteriosis, papillostenosis;
• hepatitis, liver fibrosis.

The poor condition after cholecystectomy can affect both one and several reasons. In 3% of cases, pathogenesis cannot be determined. The manifestation of anomaly occurs in adult patients. The gallway disease, requiring operation in a child - the phenomenon is extremely rare. The development of PCPs at an early age is registered in isolated cases.

Classification and main symptoms

The clinical picture of pathology depends on the reasons, is classified postcholyctectomic syndrome in three types:

1. The first group includes the consequence of surgical intervention on the organs of the hepatobiliary system, which was undertaken after incorrect diagnostics. As a result of the error, the patient's well-being was improved, the symptoms of the PCEC appeared.
2. To the second form - incorrectly carried out cholecystectomy, which damaged the gall duct (choledoch) or when removing the organ, a long fragment remained unacceptable. Possible appearance on the seam of fistula or localization of the inflammatory process in the pancreas.
3. The third group, the most common, refers dysfunction of the digestive tract, directly spasm sphincter adjusting the bile outflow in the duodenum.

The main sign of the syndrome is the bouts of pain lasting 15-25 minutes for two months and longer. Local in the upper part of the peritoneum, giving up in the hypochondrium and back on the right side with a violation of the work of the choledoch and the ring-shaped muscle. If the function of the pancreatic sphincter is affected, pain irradiates left Or wears a sinking character, duck with a slope. There may be unpleasant feelings immediately after eating, starting sharply during sleep at night with vomiting and nausea.

Postcholycistectomic syndrome is also accompanied by the symptoms of the second plan:

1. Diarrhea with frequent liquid defecation, with a sharp specific smell. Steaters characterized by an oily chair with glossy glitter.
2. Dyspepsia against the background of the growth of pathogenic bacteria in the intestinal microflora.
3. Excess gas formation, bloating abdominal cavity.
4. Hypovitaminosis due to poor DPK suction.
5. Violation of the epidermis in the corners of the mouth in the form of cracks.
6. Weakness, rapid fatigue.

An accompanying symptom is a loss of body weight by 5-10 kilograms, up to exhaustion.

Diagnostics

The clinical picture of anomalous state after removing the gallbladder does not have a certain symptomatology characteristic of the disease. Therefore, to diagnose postcholectectomic syndrome is necessary, taking into account the integrated approach. Events are aimed at clarifying the causes for full therapy.

To determine the states underlying the development of pathology, a laboratory blood test is prescribed, according to the results, it is confirmed or the presence of an inflammatory process is confirmed. Instrumental research is aimed at identifying dysfunction internal organsaffecting the work of the biliary system. Diagnostics is based on application:

1. Rentgen stomach using a special substance to identify ulcers, spasms, neoplasms, oncological tumors.
2. MSCT (spiral computed tomography), which allows determining the state of vessels and digestive organs, the fact of inflammation of the pancreas.
3. MRI (magnetic resonance imaging) liver.
4. Ultrasound (ultrasound examination) of the peritoneum to detect the remnants of the accretions overlapping ductures.
5. Radiography of the lungs, perhaps the cause of pain is the presence of abnormal processes in the body.
6. Fibrogastrododenoscopy of the duodenum.
7. Scyntigraphy, allowing to identify bile impairment, the procedure is carried out using a special marker, which shows the place of stagnation of the secret.
8. Pressure gauges and sphincter.
9. ECG (electrocardiogram) cardiac muscle.

The mandatory method for diagnosis and the most informative refers to endoscopic retrograde pancreatocholangiography (RHPG), which allows determining the state of biliary channels, the velocity of the secret, the location of the localization of stones.

Treatment

The elimination of pathology is carried out by conservative therapy, if it is based on a violation of the internal organs. Repeated surgical intervention is shown in the detection of fragments of stones or the discrepancy between the edges of the operational seam of the biliary system. To normalize the state of patients with postcholectomic syndrome, treatment with recipes of alternative medicine is recommended.

Preparations

Medicase therapy is carried out by appointment:

• enzymes: "Panzinors", "Pankreatin", "Creon";
• probiotikov: "Enterol", "Laktovit", "DuyFalak";
• blocker calcium channels "Sportsmomen";
• hepatoprotectors: "Galstina", "Hofitol", "Hepaben";
• anti-inflammatory funds: "ibuprofen", "paracetamol", "Aceclofenak";
• holinolithics: "Platifillin", "Sawsm Combous", "Atropine";
• antibacterial action preparations: "Biseptol", "Erythromycin", "Ceftriakson";
• sports Susmolitikov: "Gimekromon", "Mezhevierin", "Drozerin";
• mineral and vitamin complex in the composition of which iron is located.

Tactics of treatment depends on the disease that was a starting mechanism for the development of post-olecistectomic syndrome.

Folk remedies

It is possible to be treated from the illness by the Councils of alternative medicine after consulting a doctor, provided that there is no allergic reaction to components. Recipes are aimed at normalizing the liver and eliminating the gallbladder stones. To obtain infusion and decoctions, the collection of medicinal herbs and natural ingredients is used. Recommendations of folk healers:

1. To remove the accretions, the nettle root (100 g) is crushed, poured in advance prepared boiling water (200 g), it is withstanding on a water bath for 1 hour, filtered, drinks 5 times 1 teaspoon.
2. With the disease of the liver and the gallbladder, a means cooked from Borshevik and honey seeds in equal proportions is recommended in 5 minutes before breakfast, lunch and dinner at 0.5 tbsp. l.
3. Fresh crushed ivy (50 g) is poured 0.5 liters of red dry wine, it is seven days, is used for a small throat after meals.

To normalize the operation of the digestive tract complicated by the manifestation of diarrhea or constipation, the following is recommended: with liquid defecation - the field of field horsetail (50g) is mixed with IIV syrup (50 g), divided three times, drink during the day. With a difficult act, an effective way is to receive sesame oil on one teaspoon in the morning, day and evening.

Chronic calculous cholecystitis, often referred to as a gall-eyed disease, is an ancient satellite of humanity. It is argued that the gallstones were found in the bustling bubble still among the ancient Egyptian mummies long before the beginning of the Christian era, and the first descriptions of the bile stones made on the material of the openings belong to the period of late Middle Ages.

The prevalence of choletiasis (internationally recognized term) is very large, and over the past 30-5 years it increases steadily: in the UK - 3.4 times, in Japan - 5.6 times, in Russia 2.8 times. In Switzerland, according to autopsy, choletiasis was revealed in 24.1% of cases, including 18.6% of men and 35.3% of women; In Germany - in 24.7% (13.1% of men and 33.8% of women). At the same time, according to the data for 1930-1964, the bile stones were discovered only in 13.9% of cases - in 8.6% of men and in 20.4% of women.

According to the Metakov Remark V. G.

Vasilenko, "The biliary disease is a fee for a long and fusion life." A significant part of women, patients with choletiasis, are determined by the risk factors united by the concept of "four F".
Female Over Forty - women older than 40 years;
FAT - prone to obesity;
Flatulent - with a stubborn meteorism;
FERTILE - multi-venture.

Such a large number of people suffering from choletiasis explains the ever-growing number of annual surgical interventions, which are held on chronic calculous cystitis and its complications. Thus, in Russia, the number of cholecistectomy during one year reaches 150 thousand, in the USA - 350-500 thousand, and in the last 10-15 years already approached 700 thousand.

The consequences of cholecystectomy in the form of numerous pathological functional and organic syndromes reveal on average in 30% operated on. This determines the clinical significance of the problem of postcholecistectomic syndrome.

However, studies devoted to the study of postcholectectomic syndrome is published in recent years unjustifiably not enough.

The term "postcholecistectomic syndrome" was proposed in 1950. V. Pribram, by analogy with the term "post-money syndrome" and initially combined only functional pathological syndromes, due to the removal and loss of its reservoir, concentration and motor-evacuator functions.

We, however, consider the comparison of the term "postcholecistectomic syndrome" and "post-gastrase syndrome" not quite correct. With a total or subtotal gastrectomy, the reservoir, secretory, motor-evacuation, bactericidal functions of the stomach are not only falling out, but also a serious surgical injury is applied, since the transit of the edible chims is completely excluded as a result of the operation. The contents of the same stomach cult comes on an anastomosis directly into the current intestine; The regulatory role of the pyloric sphincter is also eliminated.

In subsequent years, the term "postcholecistectomic syndrome" without sufficient grounds began to give expansion significance, including in addition to the functional disorders due to the removal of the gallbladder and the loss of its functions, a complex of symptoms that do not have and cannot have a direct causal connection with cholecystectomy.

Thus, the concept of "postcholectectomic syndrome" additionally includes:
symptoms associated with technical errors of operational intervention;
Symptoms caused by pathological (organic) processes complicating the course of chronic stone cholecystitis before surgery that could not be eliminated during the surgical removal of the gallbladder;
Symptoms associated with accompanying chronic stone christiest diseases of the gastroduoden-cholangiopancreatic complex, not recognized before the operation. Trying to justify this position, it is usually referred to that the functional disorders associated with the removal of the gallbladder are extremely rare (in 1-5% of cases), and various pathological (mainly organic) symptoms and syndromes after cholecistek-tomia are disturbed by patients significantly More often (20-40%). L. Gloucal believes that this is a kind of compromise, a way out of the created complex situation. According to W. Bruhl, the term "postcholecistectomic syndrome" has become a kind of a speculator (Schlagwort), we will have a diagnosis that does not carry a specific content that allows doctors not to spend efforts to find out the true cause of disorders arising after the operation.

At various times, a lot of synonyms of the term "postcholectectomic syndrome" were proposed: recurrence after cholecystectomy, pseudo-vaculates after cholecystectomy, therapeutic complications after cholecystectomy, syndrome after cholecystectomy and others, but none of them could become an alternative to the brief and colaful term "postcholecistectomic syndrome", Despite all its flaws (convention, non-specificity). This term is preserved and in the international statistical classification of diseases and problems associated with health, the 10th revision: PostcholecyStectomy Syndrome. Of course, not so much the term itself is important, how much the meaning we invest in it. We consider it necessary to present our own point of view on this controversial terminological problem.

"Postcholecistectomic syndrome" is a concept (term), which combines a complex of functional disorders of the biliary system, developing in part of patients after cholecystectomy about chronic stone cholecystitis and its complications. The basis of functional disorders is the loss of the basic functions of the gallbladder after its removal (reservoir, concentration, engine-evacuator). No convincing grounds for the expansion interpretation of the term "post-olecistectomic syndrome" and the inclusion of organic changes that arose as a result of technical defects of operational intervention, Made insufficiently qualified or negligent surgeons that are observing patients with suffering after surgery. I. Magyar exactly calls them "Merchant Surgeons" (inept surgeons - "shopkeepers").

There are no direct relationship to post-olecistectomic syndrome and diseases, complicating the course of chronic stone cholecystitis, long before the operation, which no longer warned, or eliminate them, because it was completed too late. After cholecystectomy, these diseases (biliary-dependent secondary pancreatitis, etc.), gradually progressing, begin to dominate the clinical picture and mistakenly interpreted by doctors and patients as the consequences of cholecystectomy.

Thus, one group of authors is inclined to consider postholecistectomic syndrome, as a purely functional syndrome due to the loss of remote gallbladder functions; Another considers the inclusion in this concept of organic processes associated with the technical errors of the operation, as well as with diseases developed in patients with chronic stone cholecystitis as complicated to cholecystectomy.

Roman consensus-II (1999) on functional disorders of the digestive system proposes to consider postholecistectomic syndrome as a purely functional syndrome and gives it the following definition: "Postcholycystectomic syndrome is characterized by the dysfunction of the sphincter Oddi, due to the violations of its contractile function, impeding the normal bile outflow in the duodenum, in the absence of organic obstacles. "

The other definition is given supporters of the expansion interpretation of post-olecistectomic syndrome: "Postcholecistectomic syndrome is a set of functional or organic changes related to the pathology of the gallbladder or a protocal system arising after cholecystectomy or aggravated by it, or developed independently as a result of technical errors. We are supporters of the first definition with the substantial reservation that functional disorders arising after cholecystectomy are not limited to the dysfunction of the Sphinteer ODDE, but include a number of other functional disorders, primarily the functional form of chronic duodenal obstruction syndrome, or a duodenal state.

It is important to emphasize that the abbreviation of "postcholecistectomic syndrome" cannot have an independent value and requires decryption indicating those specific reasons that underlie the developed disorders: "Postcholycistectomic syndrome: dysfunction (hyperthonus) ODDI sphincter"; "Postcholycistectomic syndrome: postoperative traumatic stricture of Kolado"; "Postcholecistectomic syndrome: chronic biliary-dependent (secondary) pancreatitis."

Etiology and pathogenesis
With properly established testimony to cholecystectomy and technically flawlessly performed operation, good results are observed in 95% of patients.

This provision is confirmed by the clinical casuistry, indicating that the absence of a gallbladder is not accompanied, as a rule, any serious functional consequences. So, N.P. Fedorova presented a description of the rarest case of congenital anomaly - complete absence gallbladder. It is important to note that up to 47 years old patient did not make any complaints and did not appeal to doctors.

We recommend distinguishing:
functional (true) post-olecistectomic syndrome due to the removal of the gallbladder and the loss of its functions;
Organic (conditional) postcholectectomic syndrome associated with the technical errors of surgical intervention and / or with complications of chronic stone cholecystitis developed long before the operation that were not diagnosed to nor during operation and could not be eliminated by cholecystectomy. Recognizing that in the second case, the term "post-olecistectomic syndrome" in principle is unacceptable, we have not yet seen alternatives to him and consider it to be allowed to preserve it before the appearance of a more accurate term.

Most researchers noted the essential predominance of organic forms of post-olecistectomic syndrome.

The causes of functional forms of post-olecistectomic syndrome are studied quite fully. These are primarily the various sphincter dysfunction Oddi. Sphinteer Oddi is located in a strategically important place: at the exit of the total bile and main pancreatic ducts, which merge in the wall of the duodenum, forming a common channel and an ampoule, and open in the region of a large duodenal papilla. ODDI sphincter regulates the arrival of the bile and pancreatic juice in the twelfth-point pan of digestion and prevents the reflux of duodenal content in the overall bull and main pancreatic ducts outside the digestion. Everybody through the sphincter is approved in the twelfth intestine to 1-1.2 liters of bile and 1.5-2 liters of pancreatic juice.

Sphinteer Oddi has a complex structure. It consists of three smooth muscle formations: the sphincter of the total bile duct, the sphincter of the main pancreatic duct and the sphincter of the Bolshoi Douodetal Pacific (Westfal), which is degrading its cavity (ampoule) from the twelve intestine, preventing duoden-biliary and duoden-pancreatic refriges. The total length of the sphincter is approached from 1.5 to 3.5 cm.

The basal pressure in the cholester is about 10 mm Hg, and in the sphincter zone are approached 19-20 mm. With a reduction in the sphincter, approve the pressure in it increases to 120 mm Hg. (from 50 to 150 mm), and its reductions occur 4 (3-8) times in minus duration from 1 to 4 s. Outside the digestion, the sphincter is apparently closed. When the eating chimney is received into the denotian intestine under the influence of nerve and humoral mechanisms, the tone of the sphincter is applied, and the bile and pancreatic juice are highlighted in the duodenum. You can define the motor activity index of the sphincter ODDI: it is equal to the amplitude of its abbreviations, multiplied by their frequency per minute. With different pathological processes in the biliary system or the duodenal intestine and its surrounding organs, as well as as a result of visceerisceral pathological reflexes, emanating from other affected organs of the abdominal cavity, dysfunction (dyskinesia) of the sphincter Oddi are developing, especially often after cholecystectomy.

In the regulation of the functional state of the sphincter, approximate, intestine and sub-sormous nerve plexus, the peptidegic nervous system and intestinal hormones (cholecystokinin-panopozimine, secretine, somatostatin, Mothilin, Bombzin, etc.) participate.

There are two main forms of sphincter dysfunction Oddi:
1) Hypertonus - raising basal pressure up to 40 mm Hg. with the simultaneous increase in the frequency of its abbreviations;
2) hypotonus - a decrease in basal pressure in the sphincter zone Approach to 10-12 mm Hg.

Paradoxical response to the action of cholecystokinin is possible: spasm sphincter Oddi instead of relaxing it. With postcholycistectomic syndrome, according to the criteria of Hogan-Geenen, the dysfunction of the sphincter dday is detected in 24% of patients.

The main causes of the sphincter dysfunction are ODDI:
violation of local neuromoral regulation mechanisms;
psycho-emotional impacts;
Viscero-visceral pathological reflexes, for example, in the irritable silence syndrome, described "irritated" Sphinteer Oddi.

With the hypertonus of the sphincter, the yoy and pancreatic juice is hampered in the duodenum, the pressure in bile and pancreatic ducts increases, increases pain syndrome. The hypotonus creates the conditions for penetrating the duodenal content in the overall bull and main pancreatic ducts with serious clinical consequences.

The most important cause of functional disorders after cholecistek-tomy is also the development of chronic duodenal obstruction syndrome. In compensated and subcompensated stages of chronic duodenal obstruction syndrome, hypertension is observed in the lumen of the duodenum, and in decompensated - hypotension and dilatation of the duodenum.

Like postcholycistectomic syndrome, chronic duodenal obstruction syndrome may have a functional and organic nature. It is the functional forms of chronic duodenal obstruction syndrome, along with the dysfunction of the sphincter Sphinteer, in 18-20% of cases are the main cause of true postcholectectomic syndrome.

Tonus and duodenal motility are subordinate to the same regulatory mechanisms as the Sphinteer Approve. The intramural nervous system of the duodenum, peptidegic nervous system and intestine hormones are involved in their regulation. The stimulating effect on the motorcy and the tone of the duodenum is a wandering nerve and a hormone hormone, and the sympathetic nerve, the peptidegic nervous system and the hormone of somatostatin reduce the tone of the duodenum and brake her motility. Defeat nerve plexuses The duodenum, primarily interoperable, occurs as a result of jet and degenerative processes in the duodenum, including in the reception areas of cholinergic muscarinic effects. Vegetative dystonia and pharmacological wagotomy caused by a certain meaning long use M-cholinoblocators. A rare cause The functional syndrome of the chronicle of duodenal obstruction is the hyperplasia of D-cells in a duodenum intestine that produce somatostatin. In addition, cases of the development of functional forms of chronic duodenal obstruction syndrome at somatized depression, often disguised, which is usually not recognized by doctors. The secondary forms of chronic duodenal obstruction syndrome, developing in various pathological processes in the duodenum and organs surrounding it, are primarily found, primarily after cholecystectomy about chronic stone obstruction, as well as with a duodenal ulcer disease, especially with postbulbar localization of ulcers, with chronic atrophic Duodenitis with the involvement of seats of somatostatin reception and the development of endogenous somatostatin deficiency.

Consequence of the development of chronic duodenal obstruction syndrome with hypertension in the duodenzia, is the growing cholestasis and stagnation in pancreatic ducts, the appearance of duodenogastral, and then gastroesophageal reflux with the development of reflux-gastritis and reflux-esophagitis; Simple dysbioma (excess microbial growth syndrome in the small intestine). In some cases, various psychological syndromes are addressed by postcholycistectative syndrome. As the consequence of cholecystectomy for a long time We considered the Dilatation of Kolado, which, as believed, after removing the gallbladder, should at least partially assume the function of the bile reservoir, which is produced in the liver continuously; However, this assumption could not be confirmed in the future.

Organic (conditional) forms of postcholectectomic syndrome. Among the causes of organic postcholyctectomic syndrome, due to technical errors of surgical intervention, it is necessary to name:
Kolado stricture, developed as a result of its traumatic damage (lateral injury) during operation (6.5-20% of cases);
Left long (\u003e 1 cm) Culture of bubble duct - imported, extended, with stones or stones (Remnant Cysstic DUCT): 0.9-1.9%;
amputamental neuro or granule developed around the remaining seam;
The residual (left) stone of the total bile duct (Residuale Stone), which migrated from the gallbladder and unrecognized before and during surgery (5-20%);
recurrence of gallstone in a choleret formed around the left suture;
SUNTING Safety process with deformation and narrowing of Kolado;
Traumatic damage to a large duodenal papilla during surgery (when sensing or extracting a knocked bile stone from a large duodenal duodenal ampoule) with the development of papillostenosis (11-14%);
An incomplete cholecystectomy with the left part (croes) of the gallbladder adjacent to the bubble duct (most often it is part of the bubble funnels) because of the devices and inflammatory edema developed here; In the future, it is possible to form a "reserve" gallbladder by dilatation of its remaining part (Pseudogallenblase - German authors, reformed Gallbladder - English);
Infectious complications (ascending infectious cholan-git) and other a group of organic changes detected in patients after cholecystectomy is a consequence of various complications of chronic stone cholecystitis developed before surgery, but not timely diagnosed, which could not be eliminated by removing the gallbladder . Before the operation, they masked the symptoms of the underlying disease - chronic stone cholecystitis, and after cholecystectomy began to dominate in the clinical picture and mistakenly treated as the consequences of operational intervention:
biliary-dependent (secondary) chronic polycestitis;
ulcerative disease or secondary (symptomatic) duodenal ulcers, especially when the postbulbar localization of ulcers, impessing the detection of the ulcer defect ("Les Formes Biliares Des Ulcers Duodenaux" - French authors);
parapapillary duodenal diverticulus, often complicated by papillostenosis, bile and pancreatic hypertension flowing with severe pain syndrome;
Papillostenosis, complicating the course of chronic stone cholecystitis even before surgery, as a consequence of multiple microtraumamimization of a large duodenal nipper by microlys, migrating from the gallbladder and duodenum;
hernia of the esophageal hole of the diaphragm simulating postcholycistectomic syndrome;
secondary lesions of the liver with a long flow of chronic stone cholecystitis (cholestatic or jet hepatitis; fluid hepatosis and liver fibrosis);
Miritzzi syndrome (stenosis of a choledoch, due to the bile stones of the bubble duct with the transition of the inflammatory process from the bubble to the overall bile).

Clinical picture and diagnostics
Clinical manifestations of postcholectectomic syndrome are diverse, but nonspecific. They are mainly due to three groups of reasons:
functional disorders - the dysfunction of the sphincter dday and the functional forms of chronic duodine insufficiency syndrome;
complications of the main disease involving into the pathological process of neighboring organs - pancreas, liver, stomach, small intestine, etc.;
The consequences of technical errors admitted during surgery.
The clinical signs of post-olecistectomic syndrome sometimes appear immediately after the operation, but it is also possible "light gap" of various durations before the appearance of its first symptoms.

With the residual and recurrent bile stones of the total bile duct, repeated attacks of bile colic are possible, which in part of cases are accompanied by a mechanical jaundice. More often, the feeling of gravity in the right hypochondrium and epigastrics prevails, dyspeptic phenomena (nausea, vomiting with an admixture of bile, bitch in the mouth, air or bitter flavor belching, irregular chair with a tendency to constipate). Occasionally, a taxed diarrhea is possible, developing usually after abundant food, taking oily and acute food (Diarrhea Prandiale), as well as when taking cold carbonated drinks. Often patients are concerned about stubborn meteorism, as a manifestation of thick-binded dysbiosis. A part of the patients notes the connection of dyspeptic disorders with the effects of psycho-emotional factors: voltage, anxiety.

With functional (true) forms of post-olecistectomic syndrome, the described symptomatology has, as a rule, transient (transient) and unprovers. With organic (conditional) forms of post-olecistectomic syndrome, it is in constancy and progressive flow. In the case of infectious complications of cholecystectomy (ascending infectious cholangitis, etc.), fever appear, octs, pouring sweat, jaundice, skin itch and other signs of cholestasis (increase in the level of cholestatic enzymes, hyperbilirubinemia due to the associated fraction, etc.).

In papillostenosis, a parapapillary duodenal diverticulus often develops biliary-dependent (secondary), there is a phenomenon of "dodging pancreatic enzymes" into the blood and their increased excretion with urine; An intense pancreatic painful syndrome with typical irradiation in the back and in the form of a left-sided half-softeaux appears in the form of a left-sided semi-displacement. There was no suggestion that in patients with cholertiasis, the liver produces potentially lithogenic bile and determines the primary disorders of cholesterol and phospholipids metabolism. In the morphological study of the remote gallbladder, the majority of patients with choletiasis reveal the inflammatory process in the wall of the gallbladder - chronic stone cholecystitis.

Rare complications of cholecystectomy are described:
Chronic biliary fistula after surgery and removal of the Kera drainage without a tendency to his healing, most often due to the obturation of extrahepatic biliary tract;
the formation of bubble-thick fistula (fistula) with a stubborn rolling diarrhea;
Chronic intestinal lesion that simulates Crohn's disease.
A small part of the patients detects of choledoch cysts, followed by their aneurysmatic dilatation.

The involvement of the liver in the pathological process with chronic stone cholecystitis is manifested after cholecystectomy with a violation of its functions (cytolysis syndromes, cholestasis, hepatocellular insufficiency, etc.).

Instrumental methods for diagnosing postcholecystectomic syndrome. Among the tool methods for verifying the diagnosis of post-olecistectomic syndrome, in addition to routine (oral and intravenous chopper), highly informative non-informative and invasive diagnostic techniques have been used recently. With their help, it is possible to determine the anatomy-fun-coherent state of the extrahepatic biliary tract and the sphincter Odda, changes in the duodenum (ulcerative defects, lesions of large duodenal syndrome, the presence of a parapapillary diverticule; reveal other organic causes of chronic duodenal syndrome syndrome) and in its surrounding organs - pancreas, liver, retroperitoneal space, etc.

From non-invasive diagnostic methods should be primarily called transabdominal ultrasonography, revealing choledocholithiasis (residual and recurrent Koladochi stones, including a large duodenal chipped in an ampoule). It allows you to evaluate the anatomical structure of the liver and pancreas, to identify the dilatation of the total bile duct. Diagnostic features ultrasound diagnostics It can be elevated when using endoscopic ultrasonography and functional ultrasonic samples (with a "fat" test breakfast, with nitroglycerin). Such complex diagnostic manipulations are carried out under the control of the ultrasound, as a thin game aiming pancreatic biopsy or the imposition of percutaneous christsechen cholangiotomas.

Endoscopy of the upper digestive tract deposits determines the presence of pathological processes in the esophagus (reflux-esophagitis, erosion, ulcers, Barrett esophagus, Cancer), stomach, duodenum (ulcer, papillitis, papillostenosis and cancer of a large duodenal papillary, parapapillary duodenal diverticulter) and allows them to spend them differential diagnosis using sighting biopsy and subsequent histological learning of biopsy Removes duoden-garbage and gastroesophageal reflux.

Endoscopic cholangiography and sphincteromanometry allow:
identify the presence of residual (left) and recurrent bile stones in the choledoch;
Detect the long-cult valuable duct left by surgeons;
Detect changes in the large duodenal zone (papillostenosis, gaping);
Determine the pressure in the choledoch and the Sphinteer Appa;
If necessary, make a sighting biopsy.

A peculiar breakthrough in the diagnosis of pathological processes in the extrahepatic biliary tract and their sphinctermate provides computer hepatoblexinctigraphy. Thanks to this method, the possibility of continuous registration of the passage of bile on the wilderness of the gallways using radionuclides during the entire study time, as well as the preparation of complete information on the state of the Sphinteer Oddi, the detection of borterate disorders and the degree of underdevelopment of the biliary tract, the differentiation of the hepatocellular and mechanical jaundice differentiation. The method is not only highly informative, but also physiological, and the radiation load is minimal. Endoscopic retrograde cholangiopancopyography is a very valuable invasive method for the diagnosis of pathological changes in the area of \u200b\u200bpancreatic and extrahepatic bile ducts. It gives an exhaustive information on the state of extrahepatic bile pathways, large pancreatic ducts, reveals left and recurrent bile stones in the choleret and ampoule of a large duodenal papilla, the stricture of the total bile duct, as well as papillostenosis, obstruction of the biliary and pancreatic ducts of any etiology. A significant disadvantage of endoscopic retrograde cholangiopanmatography is a high risk (0.8-15%) of serious complications, including acute pancreatitis.

Magnetic resonant cholangiopancratography - non-nasive, highly informative diagnostic method, which can serve as an alternative to endoscopic retrograde cholangiopancreatography. It is unnecessary for the patient and deprived of the risk of complications. Thus, currently doctors have a fairly large arsenal of highly informative diagnostic methods For recognition of various forms of postcholectectomic syndrome.

The classification of causes and clinical syndromes developing after cholecystectomy has not yet been developed. We offer taking into account the comprehensive critical analysis of the causes and clinical manifestations of postcholectectomic syndrome the following version of the working classification. Working classification of the causes and consequences of cholecystectomy, carried out about chronic stone cholecystitis and its complications

Functional (true) postcholecistectomic syndrome:
- dysfunction of the Sphinteer Oddi (Hyperthonus, hypotension);
- functional form of chronic duodenal insufficiency syndrome;
- Other functional disorders caused by somthi-zoned mental depression, sublicasy dysbioma (excess microbial contamination of the small intestine), etc.

Organic (conditional) postcholecistectomic syndrome:
1. The consequences of errors and errors of surgical intervention: - post-traumatic scar stricture of Kolado;
- left long bubbleweed culture;
- residual and recurrent stones of Kolado;
- amputeluorinenevinomine and granuloma;
- postoperative backup adhesion process;
- post-traumatic papillostenosis;
- incomplete cholecystectomy with the formation of a reserve gallbladder from the abandoning of the gallbladder;
- ascending infectious cholangitis, etc.

2. Pathological processes complicated by chronic stone cholecystitis before surgery and non-diagnosed before and during cholecystectomy:
- biliary-dependent chronic pancreatitis;
- duodenal ulcer disease, including postbulbar localization of ulcers, and symptomatic duodenal ulcers;
- parapapillary duodenal diverticulum;
- papillostenosis, which developed due to long-term micro-traumatization of a large duodenal nipper by migrating microliths;
- Cysta Kolado, complicated by its aneurysmatic dilatation;
- Miritzi syndrome;
- postoperative chronic fistula (fistula);
- cholestatic and jet hepatitis, steatosis and liver fibrosis;
- hernia of the esophageal hole of the diaphragm, etc.

Treatment
With functional (true) forms of post-olecistectomic syndrome, conservative treatment methods are used. Patients must comply with a diet within the healing tables No. 5 and No. 5-P (pancreatic) with fractional meal, which should ensure bile outflow and prevent the possibility of cholestase. The rejection of bad habits (smoking, alcohol abuse, etc.) is important. If there are signs of endogenous cholecystokinine deficiency, the effect can be achieved when the Ceruletide is prescribed is a decaptide close to the mechanism of action to cholecystokinin. Dose - 2 ng / kg body weight in min intravenously drip (the duration of infusion from 15-30 minutes to 2-3 hours). When the effect is reached (the relaxation of the sphincter is apparently and the bile outflow), the infusion is stopped. In case of endogenous somatostatin failure, an octreotide is effective - a synthetic analogue of somatostatin with a greater duration of action; It is administered subcutaneously at a dose of 100 μg 3 times a day for 3-7 days before achieving the desired effect (termination of the rolling diarrhea, the relief of the symptoms of the exacerbation of pancreatitis).

In cases where postcholycystectomic syndrome proceeds against the background of severe signs of vegetative dystonia or there are grounds to assume the presence of somatized depression or viscera-visceral pathological reflexes, emanating from other abdominal organs, the effect is achieved by appointing drugs from the group "Daytime" tranquilizers or vegetative regulators: Grandaxine * At a dose of 50-100 mg 3 times a day (2-3 weeks), which, in addition, normalizes the passage of food chimus in the intestine, as well as antidepressants: cytalopram (cipramil) at a dose of 20-40 mg per day, for a long time (4- 8 weeks). Well established itself in such cases and bipolar neuroleptic Eglonil (sulpirid), which has a moderate prokine-ticure effect (50 mg 2-3 times a day, 3-4 weeks). In order to prevent the recurrence of gallstones in the choleret, as well as in the presence of signs of biliary failure, preparations of bile acids are recommended in moderate doses (10-12 mg / kg body weight per day). With organic (conditional) forms, post-olecistectomic syndrome conservative treatments are often ineffective. In these cases, there is a need to consult a surgeon.

Back in 1934, one of the pioneers surgical treatment chronic stone cholecystitis in our country S.P. Fedorov argued that choletiasis in different periods of his flow alternately turns face to the therapist, then to the surgeon. Indications for re-surgical interference with organic forms of post-olecistectomic syndrome should be established by the shared physician-therapist and the surgeon. As for the choice of a specific operation, this is the exceptional surgeon competence and depends on the nature of the revealed process (stricture of choledoch, papillostenosis, the residual stone of the choledoch, a long infected bubble ductive, containing a bile stone, etc.). Prevention of post-olecistectomic syndrome involves a comprehensive and thorough examination of patients with post-olecistectomic syndrome before and during surgery, identifying complications and related diseases that can have a significant impact on the outcome of cholecystectomy, including the cause of organic postcholectectomic syndrome. The qualifications of the surgeon and the care of all stages of operational intervention with minimal tissue injuries are crucial, including pre-and intraoperative diagnostics. It is advisable to re-examine the patient in the coming deadlines after cholecistecto-mi using non-invasive examination methods.

An important element of the prevention of postcholectectomic syndrome is also a healthy lifestyle of the patient, compliance with dietary recommendations, rejection of bad habits, long-term dispensary monitoring of the patient's condition.

Summarizing the critical overview of the problem of postcholectectomic syndrome, you can draw the following conclusions.
The terminological post-olecistectomic syndrome is a functional pathological syndrome due to the removal of the gallbladder and the loss of its functions.
The inclusion of organic processes in the concept of post-olecistectomic syndrome associated with the technical errors of operational intervention or various complications of chronic stone cholecystitis developed long before the operation, in principle incorrectly and requires the search for another terminological designation.
The diagnosis of post-olecistectomic syndrome does not have an independent value and needs a mandatory decoding indicating the specific cause of its development.
Treatment of functional (true) forms of post-olecistectomic syndrome is carried out by conservative methods and should be differentiated, take into account the nature of the functional disorders underlying it.
The prevention of post-olecistectomic syndrome is a comprehensive careful examination of each chronic stone cholecystitudo patient, during and after surgery using the entire arsenal of modern diagnostic methods.
The decision on the presence of indications for surgical treatment of patients with chronic stone cholecystitis, as well as on re-surgical intervention with organic (conditional) forms of post-olecistectomic syndrome, should be taken jointly by the attending physician (therapist) and the surgeon based on the results of a comprehensive survey. It should be remembered that the operation is only an episode in the treatment of chronic stone cholecystitis, after which the patient returns to the therapist again.

We will tell about the symptoms and treatment of postcholectectomic syndrome. This pathological condition can develop after removal of the gallbladder. The clinical picture is manifested by pain and other unpleasant symptoms.

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Symptoms and treatment

Postcholycistectomic syndrome does not include the consequences of operations that were conducted with disorders, postoperative pancreatitis or cholangitis.

Do not enter into this group patients with stones in bile ducts and with their compression. About 15% of patients are subject to development of the disease.

In older people, this figure reaches about 30%. Women get 2 times more often than men.

Characteristic symptoms

Syptomatics of the development of syndrome Next:

1. Pain attacks. The difference in the intensity will be, both strongly pronounced and duck. Stupid or cutting pain develop almost 70% of patients.
2. Disps syndrome is determined by nausea, vomiting, heartburn, diarrhea, bloating. Exciration is observed with bitter taste.
3. Malabsorption syndrome develops due to violation of the secretory function. Food is poorly absorbed in a 12-risen intestine.
4. The mass of the body is reduced, and the pace, not characteristic of the patient's body characteristics.
5. Hypovitaminosis becomes a consequence of poor digestibility of useful products and vitamins.
6. Increased temperature is characteristic of the moments of acute states.
7. Jaundice is a sign of the lesion of the liver and a violation of its functioning.

Features of the treatment of PSES.

The principles of treatment should be based on the manifestation of a symptomatic picture.

The syndrome develops in view of violations in the activities of digestive organs.

All therapeutic therapy is selected only in strict individual order. Gastroenterologist prescribes medicinal drugs supporting the treatment of the main pathology.

Furniture or dolls help to stop pain attacks. In surgical treatment, methods defines a medical consultation.

Causes of disease

The operation provokes a certain restructuring in the work of the biliary system. The main risk in the development of the syndrome concerns people who have long suffered from gallstone disease.

As a result, various pathology of other organs develop in the body. These include gastritis, hepatitis, pancreatitis, duodenitis.

If the patient, before the operation, was examined correctly and the cholecystectomy itself was carried out in technical terms flawlessly, the syndrome does not occur in 95% of patients.


There is a post-olecistectomic syndrome for reasons:

• Infectious processes in biliary tract;
• Chronic pancreatitis - secondary;
• With spikes in the area located below the liver provoking the deterioration of the work of Kolado;
• Granulomas or neurine in the postoperative seam area;
• New stones in biliary ducts;
• Incomplete removal of the gallbladder;
• Injuries in the area of \u200b\u200bthe bubble and ducts as a result of surgical manipulations.

Pathological disorders in the circulation of bile directly depend on the gallbladder.

If it is removed, then it fails in the tank function and the deterioration of general well-being is possible.

Not always specialists can accurately determine the causes of the development of this syndrome. They are diverse, and not all of them have been studied to the end.

In addition to the reasons described, it is impossible to establish this. Syndrome may occur as immediately after the operation carried out and after many years.

Galperin classification

Damage to bile ducts are early and late. Early is also called fresh, obtained during the operation to remove the gallbladder. Late are formed as a result of subsequent interventions.

Damage to ducts, unnoticed immediately after surgery, provoke health difficulties.

Syndrome can manifest itself in any period of recovery.

Famous surgeon E.I. Galperin in 2004 proposed a classification of damage to biliary ducts, which are one and the main causes of the development of post-olecistectomic syndrome.

The first classification is determined by the complexity of damage and the nature of the expiration of bile:

1. Type A develops when the gall content is leaked from the duct or hepatic branches.
2. The type B is characterized by significant damage to the ducts, with enhanced chili release.
3. The type C is observed in the case of the pathological obstruction of bile or hepatic ducts, if they occurred or the bandage.
4. Type D takes place with full intersection of bile ducts.
5. Type E is the heaviest type in which the leakage of the bile content outside or in the abdominal cavity is developing, peritonitis develops.

The second depends on the time in which the damage was detected:

• Damage during the operation itself;
• Damage that were recognized in the postoperative period.

This classification is important for thorough diagnosis and detection of methods of surgical treatment of postcholectectomic syndrome.

Clinical and Ultrasound Signs

When diagnosing the syndrome, it is necessary to analyze the history of the disease and complaints of the patient. How long does the symptomatic picture last, at what period after the operation there were symptoms.

Consilium doctors identifies the complexity and duration of previous operational interventions.

It matters, what degree of development of the gallstone disease was before removing the gallbladder to determine the main methods of treatment.

It is important for specialists to find out about the hereditary predisposition to diseases of the gastrointestinal tract.

Laboratory examination includes the following list:

1. Clinical blood test is necessary to determine the presence of inflammatory lesions, detecting leukocyte levels and possible anemia.
2. Biochemical blood test is carried out to control the level of digestive enzymes, which may indicate violations in the functioning of the liver, pancreas or the dysfunction of the sphincter dysday.
3. General urine analysis to prevent complications in the urogenital system.
4. Coprogram and feces analysis on an egg.

Abdominal ultrasound is necessary to carefully study the condition of bile ducts, liver, intestines. The method allows you to detect bile classes in the ducts and the presence of their deformation.

Retrograde cholecystopancratography is shown in suspected of the presence of stones in bile ducts, possibly their simultaneous removal. Computer tomography helps to identify different damage and formation of tumors of various localization.

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Differential diagnosis of pathology

For the formulation of accurate and correct diagnosis, differential diagnosis will be required. Through this method of research, it is possible to distinguish a disease from the other with an accuracy of 100 percent.

A similar symptomatic pattern of the course of the disease may indicate different diseases requiring different treatment.

These differences sometimes are complexly definable and requiring a detailed study of the entire anamnesis.

Differential diagnosis consists of 3 stages:

1. At the first stage, it is important to collect all these about the disease, studying the anamnesis and causes provoking the development, the necessary condition for the competent choice of diagnostic methods. The reasons for some diseases will be the same. Similarly, other problems with the digestive tract can develop the syndrome.
2. At the second stage, it is necessary to inspect the patient and identifying the symptoms of the disease. The stage is of paramount importance, especially when providing first aid. Lack of laboratory I. tool Research make it difficult to formulate a diagnosis, and ambulance Doctors should have.
3. In the third stage, this syndrome is investigated by laboratory and with other methods. The final diagnosis is established.

In medicine there are existence computer programsfacilitating the work of doctors. They allow you to carry out differential diagnostics in whole or in part.

Doctors advise in the treatment of syndrome to rely on eliminate the causes causing pain. Functional or structural disorders in the operation of the gastrointestinal tract, the liver or biliary tract often provoke bakery pain.

Antispasmodics preparations are shown to eliminate them:

• DROTAVERIN;
• Furniture.

Enzyme failure is the cause of the problems with digestion, and causes pain.

Then showing enzyme drugs:

• Creon;
• Festal;
• Panzinorm Forte.

As a result of the operation, intestinal biocenosis is disturbed.


There is a need to restore intestinal microflora using antibacterial drugs:

• Doxycycline;
• Furazolidon;
• Intetrix.

Course therapy with these drugs is required within 7 days.

Then treatment is necessary with the help of funds activating the bacterial level:

• Bifidumbacterin;
• Linex.

Drug therapy is carried out taking into account the main pathology caused by syndrome.

Indications for the use of any drugs are possible only based on the recommendations of the gastroenterologist. Principles medical treatment Can be replaced by surgical manipulations.

Characteristic signs of exacerbation

After removing the gallbladder in the body, the process of stone formation does not stop. Especially if earlier provoking factors served serious liver and pancreas pathologies.

The exacerbations of postcholectectomic syndrome can occur against the background of non-compliance with the diet. Dangerous overeating and fatty food.

The patient's food system cannot cope with the digestion of heavy products. The aggravation develops diarrhea, increasing temperature, deterioration of general well-being.

The most dangerous symptom is a pain attack. It may come suddenly, and differ strong, more often by increasing localization almost all over the abdomen.

Improper reception of drugs, ignoring the recommendations of doctors, the use of folk remedies also cause aggravation. The difficult course is characterized by complexity in diagnosis and treatment.

Another reason for exacerbation sometimes becomes blockage of ducts with new stones.

The factor of pain attack is developing suddenly and strongly. Anesthetic drugs do not help.
The patient sweats, dizziness develops, fainting. Requires urgent hospitalization.

Urgent diagnostics is important in the first hours after exacerbation. The result will be concluded in the operation.

Features of nutrition and diet

A prerequisite for the treatment of the disease is to comply with rational nutrition. To improve the operation of the digestive system, power is shown on the principle of diet No. 5.


Its main features are to fulfill the requirements:

• The optimal power supply - fractional parts, not less than 6 times during the day;
• Contraindicated hot and cold dishes;
• Mandatory inclusion of products containing fiber, pectin, lipotropic substances;
• Drinking liquid at least 2 liters per day;
• Fats and proteins should be about 100 g;
• Carbohydrates about 450 g;
• It is prohibited to use fried, oily and smoked products;
• Showing dishes: vegetable and cereal soups, low-fat varieties of meat in boiled or baked;
• Green vegetables, snobs, sweet dishes, fatty dairy products, legumes and mushrooms are not recommended.

Pay attention to the sufficient reception of vitamins, especially groups A, K, E, D, and folic acid. Be sure to increase iron preparations.

Doctors advise to reduce body weight with slow pace. Any physical and emotional loads are contraindicated.

The need for surgical treatment

Conservative treatment will be ineffective if large stones are formed in the ducts. Then a surgical operation is assigned. This method is shown and with rapid weight loss, strong pain buses combined with vomiting.

The most sparing method is endoscopic papillosphincterotomy.

Through surgical methods, bile ducts are restored and their drainage. Diagnostic operations are appointed less often when the already mentioned ways to identify the problem did not help.

Surgical operations are prescribed when developing scars on previously operated sections. Surgery treatment of syndrome is accompanied by various complications.

The poor-quality seams sailed along the edges of the wound provoke the spread of bile in the body. Need their re-imposition. Infections in the operating wound will cause purulent damage.

All preventive measures should be in attentive examination of the patient in the first days after surgical treatment. It is important to avoid inflammatory processes in the pancreas, stomach and biliary tract.

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Postcholycistectomic syndrome - a disease that includes a whole complex of various clinical manifestations arising against the background of the operation, the essence of which was to excise the gallbladder or in extracting the biliary ducts.

As a starting mechanism, there is a violation of the circulation of bile after removing the gallbladder. Also clinicians are allocated a number of other reasons, among which the inadequate implementation of cholecystectomy occupies inadequate.

The clinical picture of such a disorder is non-specific and is expressed in the emergence of repeating pain in the stomach and the area under the right ribs. In addition, there is a stool disorder, a decrease in body weight and the weakness of the body.

The diagnosis is aimed at implementing a wide range of laboratory and instrumental surveys, which must be preceded by studying the history of the disease to establish the fact previously transferred by cholecystectomy.

The treatment is completely dictated by the severity of the course of the disease, which can be both conservative and surgical.

The international classification of the diseases of the tenth revision takes a separate cipher for such pathology. Postcholectectomic syndrome code for ICD-10 - K91.5.

Etiology

The final pathogenesis of the development of such a nota remains to the end not studied, nevertheless it is believed that the main reason is the wrong process of circulating bile, which arises against the background of surgical removal of the gallbladder or stones localized in biliary passes. Such pathology is diagnosed in 10-30% of situations after previously postponed cholecystectomy.

Among the predisposing factors that cause postcholectomic syndrome is made to allocate:

• defective preoperative preparation that makes it impossible to adequately implement cholecystectomy;
• insufficient diagnosis;
• unqualified operation - here it is worth attributed to the improper introduction of drainage, injuring the vessels of a gallbladder or biliary tract, as well as partial removal of concrections;
• reduction of volumes of grid and bile acids produced;
• chronic diseases of the digestive system;
• leakage of diseases that are negatively reflected on violation of the outflow of bile in the intestines;
• microbial lesion of the 12-risos and other gastrointestinal bodies;
• partial stenosis or full obstruction of the Paters Pacific Pack.

In addition, influence the occurrence of PCPs can pathologies formed both before and after the operation. These diseases should be attributed:

• dyskinesia sphincter Oddi and;
• or ;
• adhesion process localized under the biscuits;
• diverticulus and fistulas;
• or ;
• papillostenosis;
• the formation of cysts in the general bile duct;
• infection of bile ducts.

It is worth noting that approximately 5% of patients the causes of the appearance of such a disease, it is not possible to find out.

Classification

The term "postcholecistectomic syndrome" includes a number of pathological conditions, namely:

• violation of the normal functioning of the Sphinteer Appa;
• true formation of concrections in the biliary ways damaged during cholecystectomy;
• false re-occurrence of stones or their defective removal;
• cropling during duodenal, i.e., the narrowing of the lumen of a large duodenal papilla;
• an active adhesion process with localization in the tuning space;
• chronic flow of cholepacreatitis is the simultaneous inflammatory lesion of biliary tract and pancreas;
• gastroduodenal ulcers or other defects that violate the integrity of the gastric mucosa or DPK having a different depth;
• rubtsov's narrowing of the total bile duct;
• long cult syndrome, i.e., parts of the bubble duct remaining after surgery;
• persistent pericholedheal.

Symptomatics

Despite the fact that postcholecistectomic syndrome has a large number of clinical manifestations, all of them are nonspecific, which is why they cannot accurately indicate exactly this agement, which also complicates the process of establishing the correct diagnosis.

Since the main symptom of the disease is considered painful syndrome, then clinicians are made to divide it into several types:

• gallover - the hearth protrude the top of the abdomen or the area under the right ribs. Often there is irradiation of pain in the back zone and in the right blade;
• pancreatic - localizes closer to the left harrow and spreads to the back. In addition, there is a decrease in the intensity of the symptom when the body is tilted forward;
• combined - often wears a look.

In independence from the etiological factor, the symptomatic picture of such pathology includes:

• the sudden appearance of the strongest attacks - in the overwhelming majority of situations continue for about 20 minutes and can be repeated for several months. Often, such pain appears after eating food at night;
• disorder of an act of defecation, which is expressed in abundant diarrhea - the urge can reach 15 times a day, the feces have a water consistency and a flicker odor;
• increased gas formation;
• an increase in the size of the front wall of the abdominal cavity;
• the appearance of the characteristic ration;
• formation of cracks in the corners of the oral cavity;
• lowering body weight - may be light (from 5 to 8 kilograms), moderate (from 8 to 10 kilograms) and heavy (from 10 kilograms up to extreme exhaustion);
• weakness and fast fatigue;
• constant drowsiness;
• reduction of working capacity;
• applying nausea, ending with vomit, urges;
• fever and chills;
• tension and sense of anxiety;
• gorky taste in the mouth;
• highlighting a large amount of sweat;
• development;
• and belching;
• the jaggility of the scool, mucous and skin - such a symptom of postcholectectomic syndrome is quite rare.

In cases of such a disease, symptoms in children will fully comply with the above.

Diagnostics

The appointment and study of laboratory and instrumental examinations, as well as the implementation of primary diagnostics activities, is engaged in a gastroenterologist. Complex diagnostics begins with the clinician of such manipulations:

• studying the history of the disease - to search for chronic illegality of the gastrointestinal tract or liver, increasing the chances of the development of PSES;
• analysis of life and family anamnesis;
• careful physical examination, assuming palpation and percussion of the front wall of the abdominal cavity, estimating the state of the appearance and skin of the patient, as well as the measurement of temperature indicators;
• detailed patient survey - to compile a complete symptomatic picture and establishing the severity of clinical signs.

Lab diagnostics is to implement:

• blood biochemistry;
• general blood testing and urin;
• microscopic examinations of carts;
• analysis of feces on the eggs of worms.

The greatest diagnostic value is the following instrumental procedures:

• radiography and ultrasonography;
• MSCT peritoness;
• CT and MRI;
• scintigraphy and gastroscopy;
• FGDS and RHPG;
• manometry and sphincterotomy;

Treatment

As mentioned above the therapy of postcholycystectomic syndrome can be worn both conservative and surgical character.

The inoperable treatment of the illness is primarily aimed at using such medicines:

• nitroglycerin preparations;
• spasmolitics and painkillers;
• antacids and enzymes;
• antibacterial substances;
• vitamin complexes;
• immunomodulators;
• adaptogen.

The main place in the elimination of the disease is distinguished by a diet in postcholyctectomic syndrome with several rules:

• food consumption by small portions;
• the amount of trapes per day can reach 7 times;
• enrichment of the menu by food fibers, vitamins and nutritional trace elements;
• full rejection of fried and sharp dishes, drums and confectionery, culinary fat and sala, fatty varieties of meat, birds and fish, semi-finished products and smoked, marinades and strong coffee, ice cream and other sweets, as well as from alcoholic beverages;
• eating a large number of dietary varieties of meat and fish, leguminous crops and crumbling porridges, greenery and non-acidic berries, vegetables and fruits, low-fat dairy products and wheat bread, fastening tea and compotes;
• preparation of dishes with the most gentle ways - cooking and steaming, extinguishing and baking, but without the use of fat and without obtaining a golden crust;
• abundant drinking mode;
• control over the meal temperature - it should not be very hot or overly cold;
• minimizing the use of salt.

As the basis of diet and therapy takes the gentle menu No. 5.

The use of Physiotherapeutic procedures in the process of physiotherapy procedures in the process of therapy is not excluded, among which:

After counseling with the attending physician, the use of non-traditional techniques of therapy is allowed. Folk remedies suggest the preparation of healing decoctions based on:

• calendulas and dryers;
• valerians and hop cones;
• zolotnikham and the root of Aira;
• cornflower and cleanliness;
• bird Highland and Chamomile Flowers;
• hypericum and roots of nine.

The surgical treatment of postcholectectomic syndrome is to excise on the newly formed or not fully removed during the previous operation or scars, as well as in the drainage and restoration of the patency of biliary ducts.

Possible complications

Ignoring clinical signs or unwillingness to seek re-medical care is fraught with development:

• excess bacterial growth syndrome;
• depletion or;
• deformation of the skeleton;
• in men;
• violation of the cycle of menstruation in women.

In addition, the possibility of postoperative complications such is not excluded:

• discrepancy of operating seams;
• infection of the wound;
• the formation of abscesses;

Prevention and forecast

The main preventive measures that prevent the development of such a disease is considered:

• thorough diagnosis and preparation of the patient before holding cholecystectomy;
• timely detection and elimination of gastroenterological diseases or liver pathologies that can provoke PCPE;
• proper and balanced nutrition;
• full rejection of bad habits;
• regular passage of complete preventive inspection in a medical facility.

The forecast of post-olecistectomic syndrome is directly dictated by the etiological factor that provoked the development of such a symptom complex. However, in the overwhelming majority of situations, a favorable outcome is observed, and the development of complications is observed about each 5 patient.

In the territory of Russia about gallstone disease every year, approximately 1 million people are treated in medical institutions. The number of annually carried out cholecystectomy in Russia as a whole occupies second place, yielding only the number of appendectomy. In Moscow and other major cities there are about 7,000 operations per 100,000 population per year.

Most of these operations in recent years are performed using minimally invasive technologies (small access surgery, endovideosurgery, transversum surgery). Since the number of operations on HCRs is constantly growing, the number of patients with various postoperative problems increases accordingly. According to various authors, 1-2 of every 10 operated patients after the implementation of cholecystectomy continue to test discomfort from the gastrointestinal tract, pain, disorders of the digestion process, repeated pain attacks. Gastroenterologists combine such symptoms by the term "Postcholecistectomic syndrome" (PCP). The emergence of recurrence of pain in half cases occurs during the first year after the operation, but it may appear in a long time.

Terminology and classification

The term PCP was introduced in the 30s of the twentieth century by American surgeons and is used to date. It combines a large group of pathological conditions in the hepatopancratopodododenal zone, which existed to cholecystectomy, accompanied the chivests, complicated it or arose after the operation. In many ways, this association is due to the fact that when recalculating the patient with complaints after the suffered cholecystectomy, it is rarely diagnosed to make a diagnosis without multicomponent, comprehensive survey. At the same time, the generalizing term PCEC is used as a temporary diagnosis in the process of examining the patient in accordance with the differential-diagnostic algorithm. In the future, in most cases, it is possible to find out the cause of the patient's complaints and more general term is inferior to a specific diagnosis.

All pathological conditions that are observed in patients after removing the gallbladder are divided into two main groups depending on the causes of their occurrence:

• functional disorders
• organic lesions.

In turn, to organic include:

• damage to the biliary tract;
• lesions of the gastrointestinal tract, among which the diseases of the liver, pancreas and the 12-duodenal estate should be highlighted;
• diseases and causes that are not associated with the gastrointestinal tract.

But the PCEC itself, that is, the state that emerged after the operation to remove the gallbladder is extremely rare. It is caused by the adaptive rearrangement of the biliary system in response to turning off the gallbladder from it - the elastic tank in which the bile is assembled and concentrates. In other cases there are diseases simulating PCPs.

Modern gastroenterological studies suggest that half of the patients cause complaints are functional disorders of digestion. Organic violations that are found in a third of applying, only in 1.5% of cases are indeed a consequence of the operation performed, and only 0.5% of patients with a diagnosis of PCPs require repeated operational interference. If the diagnosis of PCPs is established, issues inevitably arise related to legal and insurance liability for violations that have arisen after the provision of medical care. Therefore, among the variety of pathological conditions under the brand of PCPs, it is proposed to allocate two main groups depending on the nature of causal relations with the preceding cholecystectomy:

• diseases that are not associated with the transferred operation - as a rule, these are diagnostic errors;
• diseases that are direct consequence of surgical intervention, that is, an operating error.

Diagnostic errors include:

• The accompanying diseases or diseases in their clinical picture are not identified by the manifestation of gallstone disease. These are situations where a diagnostic error occurred and, although as a result of the operation, and was removed by the concrete gall-bubbleBut the true source of pain was not eliminated.
• Diseases of other organs located in the same area, which are not related to surgical intervention, but according to the complaints that have arisen recalls the recurrence of the gallway disease and after surgery, the patient is worried.

Operational errors include

• Residual choledocholithiasis (left in bile stones ducts).
• Papillostenosis (narrowing the area of \u200b\u200bbiliary ducts in the intestine).
• Tumors of bile ducts and heads of the pancreas.
• Damage to bile ducts during surgery.

Most of these errors are caused by an incomplete preoperative examination and following the inconsistency of the scope of operational intervention in the nature and stage of the main pathological process. This is primarily manifested in the treatment of complicated forms of bile-named disease, when only standard cholecystectomy is performed instead of more advanced intervention options. In this case, an error in the formula "Incomplete diagnosis is an insufficient volume of operation" takes place.

And finally, the most dangerous is a group of direct yatrogenic surgical complications. The PCEC symptoms in patients with different abdominal disorders appears in different periods after cholecystectomy, and sometimes it is the continuation of the same disorders that were before the operation and did not stop after it. The variety of symptoms and different deadlines for its appearance are determined by those specific reasons that underlie these violations.

Causes of "postcholecistectomic syndrome"

1. The most common cause of PCPs are stones of biliary ducts (choledocholiticiasis).It is important to distinguish true recurrences of gall-eyed disease, when the concreters in bile ducts are re-formed after the cholecystectomy, and false, when there are residual (remaining, preserved) concrections. The overwhelming majority of bile ducts are stones not deleted during the first operation. "Forgotten" stones make up 4 to 12% of all cholecystectomium performed. In recent years, after a wide introduction into practical medicine laparoscopic and endoscopic technologies, surgical tactics of treatment of patients with bile disease began to change. Nowadays, choledocholithiasis is not a contraindication to laparoscopic cholecystectomy and two-stage treatment is considered to be a standard approach to this category: endoscopic papillosphinctrotomy and removal of candidate from choledoch, followed by laparoscopic cholecystectomy. An inverse sequence of stages is possible when a single small-sized concrete is revealed in the cholel, which is left to remove the endoscopic method in the postoperative period.

2. Changes in a large duodenal papilla (BDS) of both organic and functional character.It is often that the emergence of recurrences of pain after surgery, temperature or jaundice, although the gallbladder is already removed.

Causes functional. Completed cholecystectomy leads to a temporary (up to 6 months) to strengthen the tone of the bds sphincter in 85% of patients. Such a state is most often due to the one-step disappearance of the reflex influence on the side of the gallbladder on the sphincter. In the future, in the absence of pathological changes in the organs of the hepatoduodenopancreatic system, the tone of the sphincter is normalized, the normal passage of bile is restored.

The organic damage to the BDS (stenosis) can be found in almost a quarter of patients operated on in the biliary ways. More often it develops as a result of traumatic damage when passing stones or arrange them in an ampoule. First, there is edema of BDS, and with long-term exposure and traumatization, scar changes leading to its narrowing. The method of choice for the treatment of stenosis BDS scar separation is endoscopic papillosphincterotomy.

In 5% of patients undergoing the removal of the gallbladder, the cause of the PCPs is the failure of the BDS, which leads to a violation of the locking function and the gaping of the mouth. Based on it lie dystrophic changes The walls of the 12-rig with atrophy of the mucous membrane and the deformation of the valve apparatus. The free receipt of the contents of the 12-rosted intestine (reflux) into the bile ducts through the gaping BDS leads to cholangitis and pancreatitis. The clinical picture is made up of pain in epigastrics and dyspeptic disorders in the form of a feeling of gravity and bloating, which occur after meals. Fibroduodenoscopy allows you to identify the gaping bds. More valuable information can be obtained during the x-ray of the stomach and duodenography: the barium suspension enters the bile ducts, sometimes an excellent ampoule BDS is visible.

When identifying this pathology, treatment is starting with conservative elimination of inflammatory changes in the 12-risen intestine. The detection of organic reasons for duodenostasis and duodenobiliary reflux is an indication for surgical treatment.

3. Stricks and damage to bile ducts.Postoperative strictures of bile ducts complicate 1-2% of surgical interventions performed on biliary tract. The narrowing of the duct arises either as a result of inflammatory changes in its wall, or is a consequence of the stone in it. But sometimes it arises due to external reasons: as a result of involving them in a scar tissue with a pepperconductous disease of a 12-risen intestine, pericholed lymphadenitis or other inflammatory phenomena in this area. There is another reason leading to narrowing of ducts - primary sclerosing cholangitis.

The main manifestations of biliary obstruction of biliary ducts are jaundice, cholangitis, outdoor bile fistula and complaints caused by the development of secondary biliary cirrhosis of the liver and portal hypertension.
Treatment of stricture of ducts can only be surgical. The choice of a method of operational intervention is mainly depends on the localization of the scar stricture, its length and the degree of obstruction, the severity of inflammatory changes. The operation should provide a full decompression of the biliary system, be, if possible, physiological, small-acting and eliminate the recurrence of the disease.

4. Cholant is one of the most serious complications of gallstone disease. If bile is poorly displayed, it occurs in stagnation, and the pressure in the biliary tract increases. This creates conditions for upstream infection. In this case, cholecystectomy removes only one source of infection, and the ducts will remain infected.

5. Next group of reasons for PSES - left by the surgeon "excessive" bubble duct and "residual" gallbladder. Specific symptoms for this option is not complications. Also characteristic pain in the right hypochondrium, temperature increase, is jaundice. As a rule, recurrence of pain occurs only when the left part of the gallbladder or excessive culture contains stones or a grinding of condensed bile.

Detect such defects operations are possible with the help of ultrasound research (ultrasound) of the abdominal organs. More efficiently and in detail the idea of \u200b\u200bthe problem will give the implementation of MR-cholangiography. Due to this study, you can clarify the length of excessive bubble duct, as well as get an idea of \u200b\u200bthe width of the ducts. The symptoms that appeared and the detection of excessive crop or the residual gallbladder are indicated to conduct a re-operation and removing them, because they may contain concrections, masculine masses, granuloma, neurine, which are the source of inflammation. However, even when revealing excessive bubble duct, it is necessary to make a thorough examination of the entire hepatopanretopodododenal zone in order not to miss another possible cause of the complaints.

6. Tumors of bile ducts as the cause of the PCPs make up 2.3-4.7%. They may not be detected during the first operation or appear later. They are distinguished by slow growth, not a sharp increase in pain symptoms. The most informative for the correct diagnosis is the MR-Hydrangiography and MSCT of the abdominal cavity with bolus contrast.

7. Diseases of the 12rostive intestine. Almost always in patients with diseases of biliary tract, pancreas and liver (in 72.5-98.5% of cases), changes from the 12-rosewood in the form of edema and hyperemia of the mucous membrane, its atrophy or disruption of the intestine function of the intestine are detected. After eliminating the source of inflammation, these disorders can decrease, but in most cases, without adequate treatment, chronic gastritis and duodenitis progress and create conditions for diagnosing PCEC. Clinical manifestations are in feeling of gravity and pain in the epigastric region, dyspeptic phenomena.

With a radiological examination, the disturbed peristalistic is determined with the slowdown in the passage of the barium suspension in the intestine or, on the contrary, accelerated evacuation with spastic peristaltic waves and duodenogastral reflux. In fibrogastrodenoscopy, signs of pronounced gastroduodenitis are detected.

Chronic disruption of duodenal patency (HNDP) is found in 0.45-5.7% of cases. Its clinical manifestations are masked by complaints similar to diseases of other organs. The pronounced pain syndrome, often an approached character, may be regarded as a manifestation of cholecystitis or pancreatitis. With the decompensated form of duodenostasis, an abundant with an admixture of bile is joined. With fibrogastodenoscopy, the mucous membrane of the stomach and 12-rosted intefinum, there is a duodenogastral reflux. The most informative to identify this form of the disease of the 12-rosewoman is a regenerative study.

The diverticulus of the 12-square intestine is found in 2-3% of cases. Usually they are located on the inner wall of the intestine in the middle third of the descending part, where the muscle frame of the wall is weakened as a result of vessels and ducts passing in this region. Clinical symptoms are manifested in the form of pain, less often vomiting. Sometimes jaundice joins with cholangitis phenomena. In diagnosis leading value It has a radiographic study (duodenography). The FGDS refine the dimensions of the diverticulus, the condition of the mucous membrane and the location of the BDS. Treatment of this disease surgical.

8. Chronic pancreatitis. Chronic pancreatitis in patients undergoing cholecystectomy occurs quite often. It is with the Board that contains a large number of factors leading to the defeat of not only biliary tract, but also nearby organs. In most patients, the yield of the pancreas is reduced, enzymatic failure arises.

In all cases, technically properly performed cholecystectomy contributes to the improvement of the outflow of pancreatic juice and the partial restoration of the outer-generating function of the gland. First of all, the secretion of trypsin (by the 6th month) is restored, while the normalization of the activity indicators of the amylase can be expected only after 2 years. However, under the far stage fibrous changes Chronic pancreatitis begins to manifest itself after surgery as an independent disease with exacerbations and remissions.

Typically, pains are characterized as encircling, accompanied by digestion disorders, because the exemplary function of the pancreas is disturbed, its enzymatic activity is reduced. Later, due to fibrosis of the gland tissue, disorders of the intracerecretory function of the insular apparatus can join. Therefore, when examining such patients, in addition to generally accepted biochemical indicators with the determination of amylase and lipase, it is necessary to study the enzymatic activity of pancreatic juice, a sugar curve and a test for glucose tolerance, as well as a radiographic study of the gastrointestinal tract and bile ducts.

9. Other reasons. Violation of intestinal suction, dysbacteriosis and colitis can simulate recurrence of pain after surgery. It is necessary to remember about the hemolytic disease flowing with anemia, jaundice and splenomegaly, about diseases of the right half of the colon, the right kidney and the lumbosacral spine, causing in 15-63% of patients with pain syndrome, not related to pathological changes in the biliary system.

Thus, a thorough examination of patients with PHES is needed, including in addition to generally clinical and biochemical analyzes, ultrasound examination of the hepatopancopodododenal zone organs, fibrogastroduodenoscopy and X-ray-contrast studies of the gastrointestinal tract organs, radiocontrase studies of biliary tract (CT, RHPG or CCHG) to determine the true cause of recurrence of pain and choosing adequate treatment tactics.

Principles of survey of a patient with postcholecistectomic syndrome

First of all, the continuity and rational interaction of outpatient polyclinic, community-growing and specialized units of medical care is necessary. All patients after cholecystectomy are subject to dispensary observation in a gastroenterologist both for early detection of adverse results and for conducting preventive measures: therapeutic nutrition, physical education, a vegetable diet with a limitation of proteins and animal fats, the use of choleretic means that reduces bile lithogenicity.

Another position is the mandatory consultation of the operating surgeon after the completion of rehabilitation. At the same time, the operating surgeon receives important information On the immediate and remote results of surgical treatment. For a patient, it is valuable in that it is in the hands of a surgeon there is valuable information about the premorbid status, features and details of the operation itself, data of auxiliary pre-and intraoperative research methods.

Another important condition for examining patients with PHES is the principle of finding pathology from the most frequent reasonsTo more rare and implement research from simple to complex, from non-invasive, but often less informative methods to more traumatic, but giving more important information about the disease.

At the same time, against the background of the planned survey program, which includes numerous methods and occupying, for obvious reasons, a long period of time, it is necessary to identify situations requiring the urgent direction of the patient to the hospital. Surgical alertness should be the higher, the less time passed since the operation. This, first of all, refers to painful syndrome, accompanied by a jaundice, fever, chill, nausea and vomiting, that is, when we can suspect acute cholangitis in a patient.

Survey of the patient with an alleged diagnosis of postcholycistectomic syndrome should certainly begin with an ultrasound abdominal cavity. The result of the study will eliminate pronounced anatomical changes in the hepatopancreatoobiliary system organs and make further research more targeted.

Concerning Kt.It is useful in order to identify choledocholithiasis in the absence of pathological changes in liver and pancreas - is irrational and less informative. At the same time, the possibilities of CT are difficult to overestimate with organic changes in the hepatopanretopododododenal zone. MRI, especially performed in MR-HOLGiography mode, can give enough important information regarding the state of biliary tract, as well as the protein pancreatic system. And yet, despite the great possibilities of modern diagnostic methods, there is a group of patients who cannot identify the cause of complaints after transferred cholecystectomy.

Treatment

Treatment of patients with PCECs should be complex and aimed at eliminating those functional or structural disorders from the liver, biliary tract, gastrointestinal tract and pancreas, which underlie suffering and appeared to appeal to the doctor. Lifestyle and nutrition play a significant role in the development of HCB. Therefore, diet, food intake mode, motor regime are the most important conditions for rehabilitation after cholecystectomy operation.

A diet is assigned, which:

1) should not provoke the hepatic colic and have a harmful effect on the pancreas;

2) should be positively influenced by bile and on the outer-generating function of the pancreas;

3) contributes to a decrease in the lithogenic properties of bile;

4) improves liver metabolic processes.

Medication therapy also usually includes a combination of drugs of different classes. The basis of treatment is the normalization of the passage of bile on the overall hepatic, shared bustling ducts and pancreatic juice on the main pancreatic duct. To eliminate the most patients with relative enzymatic insufficiency in most patients, adequate enzyme support course of treatment is reasonable to improve fat digestion.

Identification of erosive-ulcerative lesions of the mucous membrane of the upper departments of the gastrointestinal tract involves the conduct of antisecretory therapy, and in the diagnosis of helicobacteriosis - eradication therapy.

The relief of meteorism can be achieved by the appointment of defoamers, combined drugs, sorbents, microcrystalline cellulose preparations. Often the HCR is accompanied by a disorder of intestinal biocenosis leading to intestinal dyspepsia. In these cases, it is advisable to conduct decontamination therapy. Then treatment with probiotics and prebiotics is carried out.

Of course, such a comprehensive examination and treatment is correct in one institution. Our clinic has all the necessary diagnostic opportunities for a full-fledged survey, treatment and rehabilitation and preventive measures.