Main symptoms and Main symptoms and syndromes in diseases of syndromes in diseases of

a liver and bile ducts. a liver and bile ducts. Methods of clinical, Methods of clinical,

laboratory and laboratory and instrumental examinationsinstrumental examinations

Khabarova Khabarova N.A.N.A.

CholecystitisCholecystitis is the is the inflammation on the gall inflammation on the gall bladder.bladder.

Etiology:Etiology:1.1. Bacterial infection diseases:Bacterial infection diseases:2.2. The most typical The most typical

microbiological agents are: E. microbiological agents are: E. Coli, Enterococci,Coli, Enterococci, Staphylococci, Streptococci.Staphylococci, Streptococci.

3.3. ННelmintic invasion: elmintic invasion: opistorchosis, asckaridosis, opistorchosis, asckaridosis, lambliosis.lambliosis.

4.4. Duodenal-billiary reflux Duodenal-billiary reflux (regurgitation of pancreatic (regurgitation of pancreatic juice or duodenal content to juice or duodenal content to the gall bladder)the gall bladder)

5.5. Cholecistitis of toxic or Cholecistitis of toxic or allergic nature.allergic nature.

6.6. Chronic inflammatory Chronic inflammatory diseases of alimentary tractdiseases of alimentary tract

7.7. Acute cholecystitis.Acute cholecystitis.

PathogenesisPathogenesisInfection may enter to the gall bladder by Infection may enter to the gall bladder by

following ways:following ways: enterogenic (from the intestine, in the enterogenic (from the intestine, in the

case of reflux);case of reflux); haematogenic;haematogenic; lymphogenic.lymphogenic.

Inflammation in the gall bladder develops Inflammation in the gall bladder develops only in the case when infection only in the case when infection contamination is combined with bile contamination is combined with bile congestion, changes of bile properties, congestion, changes of bile properties, dystrophy of gall bladder walls or dystrophy of gall bladder walls or immunodepression.immunodepression.

Clinical picture:Clinical picture:

Complaints:Complaints:- Pain in the right hypochondrium;- Pain in the right hypochondrium;- Dyspeptic syndromeDyspeptic syndrome;;- PsyPsyссhoemothoemotional disorders;ional disorders;- - The temperature is often The temperature is often

subfebrile.subfebrile.- - skin itching.skin itching.Objective signs:Objective signs: - - Moderate obesity is sometimes Moderate obesity is sometimes

observed.observed.- flatulence of abdomen; - flatulence of abdomen;

Examination of the abdomen can Examination of the abdomen can reveal its flatulence reveal its flatulence

- yellowish tint of the skin;- yellowish tint of the skin;- data of palpation: sensitivity or - data of palpation: sensitivity or

mild pain; sometimes mild pain; sometimes pronounced tenderness in the pronounced tenderness in the region of gall bladder projection.region of gall bladder projection.

Following typical Following typical symptoms may be symptoms may be revealed by revealed by palpation:palpation:

1.1. Vasilenko`s Vasilenko`s symptomsymptom

2.2. Obraztsov-Murphy Obraztsov-Murphy symptomsymptom

3.3. Ortner`s symptomOrtner`s symptom4.4. The de Mussy-The de Mussy-

Georgievsky Georgievsky symptomsymptom

Liver: usually is of normal Liver: usually is of normal sizes, but becomes sizes, but becomes enlarged in enlarged in complications complications (hepatitis, (hepatitis, cholangitis).cholangitis).

The gall bladder is The gall bladder is impalpable.impalpable.

Tender points and sites of hyperesthesia Tender points and sites of hyperesthesia on the body according to on the body according to Zakharyin and Head:Zakharyin and Head:

1.1. the region of the gall bladder (its the region of the gall bladder (its projection on the skin)projection on the skin)

2.2. epigastriumepigastrium3.3. pancreato-biliary-cystic pointpancreato-biliary-cystic point4.4. shoulder zoneshoulder zone5.5. phrenic nerve pointphrenic nerve point6.6. tip of the scapulatip of the scapula7.7. point at the edge of the 12th ribpoint at the edge of the 12th rib8.8. paravertebral points rightward from paravertebral points rightward from

the 8th to 11th thoracic vertebrathe 8th to 11th thoracic vertebra9.9. points rightwards from the 12th points rightwards from the 12th

thoracic vertebra.thoracic vertebra.

Laboratory and instrumental Laboratory and instrumental examination:examination:

1.1. Blood countBlood count2.2. Biochemical blood analysisBiochemical blood analysis3.3. Duodenal probingDuodenal probing4.4. X-Ray study. There are following X-Ray study. There are following

methods: cholecystography, methods: cholecystography, cholangiography, endoscopic cholangiography, endoscopic (retrograde)cholangiopancreatogra(retrograde)cholangiopancreatography.phy.

5.5. Sonographyc studySonographyc study

6.6. Computer tomographyComputer tomography

7.7. ThermographyThermography

Treatment:Treatment:Stage of exacerbation:Stage of exacerbation:1. bed mode during 7 – 10 days1. bed mode during 7 – 10 days2. diet 2. diet №№ 5a, warm drink; 5a, warm drink;food intake 5 – 6 time a day by small portionsfood intake 5 – 6 time a day by small portions3. 3. elimination of pain:elimination of pain:

M-cholinolitics (atropine sulfate, metacin, M-cholinolitics (atropine sulfate, metacin, plathyphyllin, gastrocepin).plathyphyllin, gastrocepin).

Spasmolitics ( papaverin, no-spa ).Spasmolitics ( papaverin, no-spa ). Analgetics (analgin, baralgin).Analgetics (analgin, baralgin).

4.4. improvement of bile excretion:improvement of bile excretion:- - cholagogescholagoges5.5. antibioticotherapyantibioticotherapy6.6. detoxicationdetoxication7.7. physiotherapy.physiotherapy.

CholangitisCholangitisCholangitis Cholangitis is the inflammatory process of bile ducts. is the inflammatory process of bile ducts. Classification: Acute and chronic Classification: Acute and chronic cholangitischolangitis catarrhal and purulent. catarrhal and purulent. Acute purulent Acute purulent cholangitis cholangitis is characterized by is characterized by

“Charcot’s triad” or “intermittent hepatic fever”:“Charcot’s triad” or “intermittent hepatic fever”:high body temperature, chillshigh body temperature, chills, , sweatingsweating, , as well as as well as

jaundice. jaundice. Liver is enlarged and painful. Spleen is sometimes Liver is enlarged and painful. Spleen is sometimes

enlarged. enlarged. Blood analysis:Blood analysis: neutrophil leukocytosis, accelerated ESR, neutrophil leukocytosis, accelerated ESR,

elevation of alkaline phosphatase and aminotransferase elevation of alkaline phosphatase and aminotransferase levels. levels.

Chronic cholangitis.Chronic cholangitis. The course of may be latent, The course of may be latent, recurrent or prolonged with septic component.recurrent or prolonged with septic component.

Clinical manifestationClinical manifestation: : Sensation of heaviness or dull Sensation of heaviness or dull

pain in the right pain in the right hypochondrium.hypochondrium.

Dyspeptic syndrome Dyspeptic syndrome Skin itching Skin itching Asthenodepressive Asthenodepressive Yellowish tint of mucous coatsYellowish tint of mucous coatsThe liver is enlarged, mild and The liver is enlarged, mild and

painful. painful.

TreatmentTreatment. Diet N 5a, . Diet N 5a, antibiotics and cholagoges. antibiotics and cholagoges.

Sometimes surgical treatment Sometimes surgical treatment is necessary.is necessary.

ultrasoundultrasound

cholangiography cholangiography

GALLSTONESGALLSTONES

Risk factorsRisk factorsCholesterol stonesCholesterol stonesThe excessive secretion of cholesterol by liver is the most important factor in stone The excessive secretion of cholesterol by liver is the most important factor in stone

formation. Increased cholesterol secretion occurs in the following condition.formation. Increased cholesterol secretion occurs in the following condition.► Females (male to female ratio 1:3)Females (male to female ratio 1:3)► ObesityObesity► Exogenous estrogenExogenous estrogen► Increased age (mostly 40 onwards) rare in youngIncreased age (mostly 40 onwards) rare in young► Diabetes mellitus (associated with high cholesterol)Diabetes mellitus (associated with high cholesterol)► PregnancyPregnancy► Rapid weight lossRapid weight lossPigment stonePigment stone► Hemolytic anemiasHemolytic anemias► Ileal disease or resectionIleal disease or resection► Infection of biliary tractInfection of biliary tract► Bile stasis Bile stasis

Clinical featuresClinical features

1.1. Asymptomatic: Asymptomatic: about 80%about 80% of cases are of cases are asymptomatic asymptomatic

2.2. Symptomatic Symptomatic gallstones manifest either gallstones manifest either as biliary colic or cholecystitis as biliary colic or cholecystitis

3.3. Biliary colic Biliary colic occurs if the stone is acutely occurs if the stone is acutely impacted in the cystic duct. Pain is felt in impacted in the cystic duct. Pain is felt in the epigastrium or right upper quadrant, the epigastrium or right upper quadrant, radiating to the interscapular region or tip radiating to the interscapular region or tip of the right scapula.of the right scapula.

InvestigationsInvestigations

1.1. UltrasoundUltrasound2.2. Endoscopic retrograde Endoscopic retrograde

cholangiography (ERSP)cholangiography (ERSP)3.3. X-ray abdomenX-ray abdomen

Classification:Classification:

1.1. Autoimmune hepatitisAutoimmune hepatitis

2.2. Viral hepatitViral hepatitееs – B (HBV), C (HCV) s – B (HBV), C (HCV) and D (HDV) and D (HDV)

3.3. Nondefined chronic viral hepatitisNondefined chronic viral hepatitis

4.4. Medicamentous hepatitisMedicamentous hepatitis

5.5. Cryptogenic hepatitis.Cryptogenic hepatitis.

Chronic Hepatitis Chronic Hepatitis is a chronic diffuse or focal is a chronic diffuse or focal inflammatory affection of the liver.inflammatory affection of the liver.

Main aethiological factors:Main aethiological factors:1.1.Viruses of hepatitis B, C and D. Viruses of hepatitis B, C and D. 2.2.Alcohol abuse.Alcohol abuse.3.3.Usage of some medicines Usage of some medicines

(aminazine, tubasid, (aminazine, tubasid, paracetamol, sulfa-drugs, paracetamol, sulfa-drugs, metotrexat, aspirin, aldomet ets metotrexat, aspirin, aldomet ets in prolonged usage)in prolonged usage)

4.4.Rarely – some metabolic Rarely – some metabolic disorders, influence of disorders, influence of hepatotropic agentshepatotropic agents..

Main clinical syndromesMain clinical syndromes

1.1. Jaundice. Jaundice. Clinical symptoms: Clinical symptoms: yellow colour of the yellow colour of the skin and sclera, skin and sclera, changes of colour changes of colour of urine and, of urine and, mucosa feces, skin mucosa feces, skin itching. itching.

Main clinical syndromesMain clinical syndromes2.2. Portal Portal

hypertension. This is hypertension. This is elevation of blood elevation of blood pressure in the bassein pressure in the bassein of V.Portae. Clinical of V.Portae. Clinical symptoms: dilatation of symptoms: dilatation of portocaval anastomoses portocaval anastomoses (dilatation of esophageal (dilatation of esophageal and hemorrhoidal veins, and hemorrhoidal veins, pointed venous pattern pointed venous pattern of the anterior abdominal of the anterior abdominal and chest wall – “caput and chest wall – “caput medusa”), ascites, medusa”), ascites, splenomegaly. Bleeding splenomegaly. Bleeding from dilatedfrom dilated collaterals.collaterals.

Main clinical syndromesMain clinical syndromes

3.3. Hepatolienal syndrome. Hepatolienal syndrome. 4.4. Hemorrhagic syndrome. Hemorrhagic syndrome. 5.5. Hepatorenal syndrome.Hepatorenal syndrome.6.6. Cholestasis. Cholestasis. 7.7. Hepatocellular insufficiencyHepatocellular insufficiency..8.8. Dyspeptic syndromeDyspeptic syndrome..9.9. Pain in the right hypochondrium. Pain in the right hypochondrium.

Clinical picture and the course of each clinical-morphological form of hepatitis have their special features.

Treatment.Treatment.The cause of chronic hepatitis should be removed in the The cause of chronic hepatitis should be removed in the

first instance: exclusion of hepatfirst instance: exclusion of hepatооtoxic influences, toxic influences, complete discontinuation of taking alcohol or exposure complete discontinuation of taking alcohol or exposure to harmful substances, etc.to harmful substances, etc.

Limitation of heavy physical loading.Limitation of heavy physical loading.Avoiding of drugs which are metabolized in liver Avoiding of drugs which are metabolized in liver

(trankvilisators, sedative agents, analgesics ets);(trankvilisators, sedative agents, analgesics ets);Diet N 5.Diet N 5. Meals 4-5 times a day by small portions.Meals 4-5 times a day by small portions.Medicamentous treatment:Medicamentous treatment:► antiviral preparationsantiviral preparations► immunostimulatorsimmunostimulators► HepatoprotectorsHepatoprotectors► In autoimmune hepatitis – glucocorticoids and In autoimmune hepatitis – glucocorticoids and

immunodepressants. immunodepressants.

Cirrhosis of the liverCirrhosis of the liver is a chronic is a chronic progressive disease characterized by progressive disease characterized by increasing hepatic insufficiency in increasing hepatic insufficiency in connection with dystrophy of the liver connection with dystrophy of the liver cells, cicatricial cirrhosis, and structural cells, cicatricial cirrhosis, and structural reconstruction of the liver.reconstruction of the liver.

The main aethiological factors:The main aethiological factors:1.1.Viruses of hepatitis B, C and DViruses of hepatitis B, C and D ( (HBV, HBV,

HCVHCV, , HBVHBV++HDV)HDV)..2.2.alcoholism; alcoholism; 3.3. protein- and vitamin-deficient diet;protein- and vitamin-deficient diet;4.4.toxic-allergic lesions;toxic-allergic lesions;5.5. cholestasis. cholestasis. The leading role belongs to the virus The leading role belongs to the virus

of hepatitis. of hepatitis.

Pathological anatomy.Pathological anatomy. Three main morphological variants of liver Three main morphological variants of liver cirrhosis are distinguished: cirrhosis are distinguished: portal portal ((septal), post necrotic, and septal), post necrotic, and

biliary.biliary. According to the morphological picture, According to the morphological picture, fine-fine- and and large-nodular large-nodular

cirrhosiscirrhosis is distinguished. is distinguished. MixedMixed variants also occur. variants also occur.

large-nodular cirrhosislarge-nodular cirrhosis fine- nodular cirrhosisfine- nodular cirrhosis

Clinical pictureClinical pictureThe following symptoms of the disease are most The following symptoms of the disease are most

characteristic of the majority of patients with characteristic of the majority of patients with various forms of liver cirrhosis.various forms of liver cirrhosis.

► Pain in the region of the liver, in the Pain in the region of the liver, in the epigastrium, or diffuse pain in the whole epigastrium, or diffuse pain in the whole abdomenabdomen..

►DyspepsiaDyspepsia.. ►Decreased work capacity, general weakness, Decreased work capacity, general weakness,

fatigue. fatigue. ► Fever is usually irregular and sometimes of the Fever is usually irregular and sometimes of the

undulant type. undulant type. ► A hemorrhagic syndromeA hemorrhagic syndrome..► Cachexia;Cachexia;► Jaundice often attended by skin itching.Jaundice often attended by skin itching.

Data of physical Data of physical examination:examination:

Inspection of the Inspection of the abdominal skin can abdominal skin can reveal dilation of reveal dilation of the veins that can the veins that can be seen through be seen through the thinned skin of the thinned skin of the abdominal wall the abdominal wall (caput medusae). (caput medusae).

► Ascites Ascites ► The liver is enlarged, The liver is enlarged,

firm, the surface is firm, the surface is sometimes irregular, sometimes irregular, and the lower edge and the lower edge sharp. sharp.

►

Enlargement of the Enlargement of the spleen is often spleen is often attended by its attended by its increased activity increased activity (hypersplenism).(hypersplenism).

"Minor" signs of cirrhosis:"Minor" signs of cirrhosis:

► spider angiomata, spider angiomata, ► erythema of the palms; erythema of the palms; ► red lustrous lips, scarlet mucosa of the mouth, red lustrous lips, scarlet mucosa of the mouth,

scarlet (lacquered) tongue; scarlet (lacquered) tongue; ► gynaecomastia (increased mammary glands) and gynaecomastia (increased mammary glands) and

other female sex characters developing in men other female sex characters developing in men (decreasing growth of hair on the face, chest, (decreasing growth of hair on the face, chest, abdomen, and the head); abdomen, and the head);

► xanthomatous plaques on the skin (observed in xanthomatous plaques on the skin (observed in patients with biliary cirrhosis of the liver);patients with biliary cirrhosis of the liver);

► Hippocrates fingers with hyperemic skin at the nail Hippocrates fingers with hyperemic skin at the nail beds. beds.

spider angiomataspider angiomata

gynaecomastiagynaecomastia

xanthomatous plaquesxanthomatous plaques

erythema of the palmserythema of the palms

Hippocrates fingersHippocrates fingers

- An active cirrhotic process is characterized by An active cirrhotic process is characterized by anemia, leucopenia, thrombocytopenia, and anemia, leucopenia, thrombocytopenia, and increased ESR.increased ESR.

- Changes in blood serum: bilirubin excretion into Changes in blood serum: bilirubin excretion into bile is disordered. Free (indirect) and bound bile is disordered. Free (indirect) and bound (direct) bilirubin increase. (direct) bilirubin increase.

- Jaundice is usually characterized by partial Jaundice is usually characterized by partial decolouration of feces. decolouration of feces.

- The presence of much urobilin in the urine - The presence of much urobilin in the urine indicates liver insufficiency. indicates liver insufficiency.

-The upset excretory function of the liver is -The upset excretory function of the liver is manifested by radioisotopic hepatography and manifested by radioisotopic hepatography and scanning of the liver.scanning of the liver.

Laboratory findings

► Affection of liver cells is manifested by Affection of liver cells is manifested by decreased concentration of serum albumins and decreased concentration of serum albumins and hypergam-maglobulinaemia which in turn hypergam-maglobulinaemia which in turn decreases the albumin-globulin coefficient. decreases the albumin-globulin coefficient. Activation of the inflammatory process in the Activation of the inflammatory process in the liver involves an increase in the liver involves an increase in the 2-globulins2-globulins..

► The blood level of lipids and cholesterol The blood level of lipids and cholesterol increases considerably in the presence of biliary increases considerably in the presence of biliary cirrhosis while activity of alkaline phosphatase cirrhosis while activity of alkaline phosphatase increasesincreases..

► In liver dysfunction there is decreased activity of In liver dysfunction there is decreased activity of cholinesterase. Transaminase activity increases cholinesterase. Transaminase activity increases in exacerbation of liver cirrhosis. in exacerbation of liver cirrhosis.

► The decreased prothrombin content, increased The decreased prothrombin content, increased antithrombin coagulative activity and decreased antithrombin coagulative activity and decreased total coagulative activity of plasma.total coagulative activity of plasma.

Instrumental examination:Instrumental examination:► Laparoscopy and especially biopsy of the liver Laparoscopy and especially biopsy of the liver

help reveal intravital morphological signs of help reveal intravital morphological signs of each variant of liver cirrhosis. each variant of liver cirrhosis.

► Varicose veins of the oesophagus are revealed Varicose veins of the oesophagus are revealed by X-rays.by X-rays.

The terminal period of the disease, irrespective of The terminal period of the disease, irrespective of the form of cirrhosis, is characterized by gastro-the form of cirrhosis, is characterized by gastro-intestinal hemorrhage and progressive signs of intestinal hemorrhage and progressive signs of functional insufficiency of the liver, with finally functional insufficiency of the liver, with finally developing coma. These are two most frequent developing coma. These are two most frequent direct causes of death of patients with liver direct causes of death of patients with liver cirrhosis.cirrhosis.

CT scanCT scan

Treatment.Treatment.1) Preventing its further liver affection with alcohol, toxic 1) Preventing its further liver affection with alcohol, toxic

substances, etc.,substances, etc.,2) Rational organization of work regimen and nutrition (high-2) Rational organization of work regimen and nutrition (high-

caloric diet rich in protein and vitamins). Patients with caloric diet rich in protein and vitamins). Patients with ascites are prescribed a diet restricted in salt.ascites are prescribed a diet restricted in salt.

3) Glucocorticosteroid hormones are given in the active 3) Glucocorticosteroid hormones are given in the active processprocess

4)Hepatoprotective agents4)Hepatoprotective agents..5)5) Diuretics (periodically in ascites).Diuretics (periodically in ascites). If ascites cannot be cured by diuretics, the fluid is If ascites cannot be cured by diuretics, the fluid is

released by paracentesis.released by paracentesis.5)5) In order to decrease the lipid content of the serum in In order to decrease the lipid content of the serum in

primary biliary cirrhosis, lipoic acid preparations are primary biliary cirrhosis, lipoic acid preparations are prescribed.prescribed.

6)6) Surgical treatment is indicated in cases with secondary Surgical treatment is indicated in cases with secondary biliary cirrhosis of the liver, e.g. in obstruction of the bile biliary cirrhosis of the liver, e.g. in obstruction of the bile duct by a stone.duct by a stone.

paracentesisparacentesis