Khabarova N.A.

1. Diseasesof a liverandbileducts. Chronichepatitis, livercirrhosis. Ethiology. Clinicalpattern. Daignostics. Complications. Principlesoftreatment. Khabarova N.A.

4. Cholecystitis is the inflammation on the gall bladder. Etiology: • Bacterial infection diseases: • The most typical microbiological agents are: E. Coli, Enterococci,Staphylococci, Streptococci. • Нelmintic invasion: opistorchosis, asckaridosis, lambliosis. • Duodenal-billiary reflux (regurgitation of pancreatic juice or duodenal content to the gall bladder) • Cholecistitis of toxic or allergic nature. • Chronic inflammatory diseases of alimentary tract • Acute cholecystitis.

5. Pathogenesis Infection may enter to the gall bladder by following ways: enterogenic (from the intestine, in the case of reflux); haematogenic; lymphogenic. Inflammation in the gall bladder develops only in the case when infection contamination is combined with bile congestion, changes of bile properties, dystrophy of gall bladder walls or immunodepression.

6. Clinical picture: Complaints: - Pain in the right hypochondrium; • Dyspeptic syndrome; • Psyсhoemotional disorders; - The temperature is often subfebrile. - skin itching. Objective signs: - Moderate obesity is sometimes observed. - flatulence of abdomen; Examination of the abdomen can reveal its flatulence - yellowish tint of the skin; - data of palpation: sensitivity or mild pain; sometimes pronounced tenderness in the region of gall bladder projection.

7. Following typical symptoms may be revealed by palpation: Vasilenko`s symptom Obraztsov-Murphy symptom Ortner`s symptom The de Mussy-Georgievsky symptom Liver: usually is of normal sizes, but becomes enlarged in complications (hepatitis, cholangitis). The gall bladder is impalpable.

10. Tender points and sites of hyperesthesia on the body according to Zakharyin and Head: the region of the gall bladder (its projection on the skin) epigastrium pancreato-biliary-cystic point shoulder zone phrenic nerve point tip of the scapula point at the edge of the 12th rib paravertebral points rightward from the 8th to 11th thoracic vertebra points rightwards from the 12th thoracic vertebra.

11. Laboratory and instrumental examination: Blood count Biochemical blood analysis Duodenal probing X-Ray study. There are following methods: cholecystography, cholangiography, endoscopic (retrograde)cholangiopancreatography. Sonographyc study Computer tomography Thermography

15. Treatment: Stage of exacerbation: 1. bed mode during 7 – 10 days 2. diet № 5a, warm drink; food intake 5 – 6 time a day by small portions 3. elimination of pain: M-cholinolitics (atropine sulfate, metacin, plathyphyllin, gastrocepin). Spasmolitics ( papaverin, no-spa ). Analgetics (analgin, baralgin). 4. improvement of bile excretion: - cholagoges 5. antibioticotherapy 6. detoxication 7. physiotherapy.

16. Cholangitis Cholangitisis the inflammatory process of bile ducts. Classification: Acute and chronic cholangitis catarrhal and purulent. Acute purulent cholangitisis characterized by “Charcot’s triad” or “intermittent hepatic fever”: high body temperature, chills, sweating, as well as jaundice. Liver is enlarged and painful. Spleen is sometimes enlarged. Blood analysis:neutrophilleukocytosis, accelerated ESR, elevation of alkaline phosphatase and aminotransferase levels. Chronic cholangitis. The course of may be latent, recurrent or prolonged with septic component.

17. Clinical manifestation: Sensation of heaviness or dull pain in the right hypochondrium. Dyspeptic syndrome Skin itching Asthenodepressive Yellowish tint of mucous coats The liver is enlarged, mild and painful. Treatment. Diet N 5a, antibiotics and cholagoges. Sometimes surgical treatment is necessary.

18. ultrasound cholangiography

19. GALLSTONES Risk factors Cholesterol stones The excessive secretion of cholesterol by liver is the most important factor in stone formation. Increased cholesterol secretion occurs in the following condition. Females (male to female ratio 1:3) Obesity Exogenous estrogen Increased age (mostly 40 onwards) rare in young Diabetes mellitus (associated with high cholesterol) Pregnancy Rapid weight loss Pigment stone Hemolytic anemias Ileal disease or resection Infection of biliary tract Bile stasis

21. Clinical features • Asymptomatic: about 80%of cases are asymptomatic • Symptomatic gallstones manifest either as biliary colic or cholecystitis • Biliary colic occurs if the stone is acutely impacted in the cystic duct. Pain is felt in the epigastrium or right upper quadrant, radiating to the interscapular region or tip of the right scapula.

22. Investigations 1. Ultrasound 2. Endoscopic retrograde cholangiography (ERSP) 3. X-ray abdomen

27. Chronic Hepatitis is a chronic diffuse or focal inflammatory affection of the liver. Classification: • Autoimmune hepatitis • Viral hepatitеs – B (HBV), C (HCV) and D (HDV) • Nondefined chronic viral hepatitis • Medicamentous hepatitis • Cryptogenic hepatitis.

28. Main aethiological factors: • Viruses of hepatitis B, C and D. • Alcohol abuse. • Usage of some medicines (aminazine, tubasid, paracetamol, sulfa-drugs, metotrexat, aspirin, aldometets in prolonged usage) • Rarely – some metabolic disorders, influence of hepatotropicagents.

30. Main clinical syndromes 1. Jaundice. Clinical symptoms: yellow colour of the skin and sclera, changes of colour of urine and, mucosa feces, skin itching.

32. Main clinical syndromes 2. Portal hypertension. This is elevation of blood pressure in the bassein of V.Portae. Clinical symptoms: dilatation of portocavalanastomoses (dilatation of esophageal and hemorrhoidal veins, pointed venous pattern of the anterior abdominal and chest wall – “caput medusa”), ascites, splenomegaly. Bleeding from dilatedcollaterals.

34. Main clinical syndromes • Hepatolienal syndrome. • Hemorrhagic syndrome. • Hepatorenalsyndrome. • Cholestasis. • Hepatocellular insufficiency. • Dyspeptic syndrome. • Pain in the right hypochondrium. Clinical picture and the course of each clinical-morphological form of hepatitis have their special features.

40. Treatment. The cause of chronic hepatitis should be removed in the first instance: exclusion of hepatоtoxic influences, complete discontinuation of taking alcohol or exposure to harmful substances, etc. Limitation of heavy physical loading. Avoiding of drugs which are metabolized in liver (trankvilisators, sedative agents, analgesics ets); Diet N 5.Meals 4-5 times a day by small portions. Medicamentous treatment: • antiviral preparations • immunostimulators • Hepatoprotectors • In autoimmune hepatitis – glucocorticoids and immunodepressants.

41. Cirrhosis of the liver is a chronic progressive disease characterized by increasing hepatic insufficiency in connection with dystrophy of the liver cells, cicatricial cirrhosis, and structural reconstruction of the liver. The main aethiological factors: • Viruses of hepatitis B, C and D (HBV, HCV, HBV+HDV). • alcoholism; • protein- and vitamin-deficient diet; • toxic-allergic lesions; • cholestasis. The leading role belongs to the virus of hepatitis.

44. Pathological anatomy. Three main morphological variants of liver cirrhosis are distinguished: portal (septal), post necrotic, and biliary.According to the morphological picture, fine- and large-nodular cirrhosis is distinguished. Mixed variants also occur. large-nodular cirrhosis fine- nodular cirrhosis

47. Clinical picture The following symptoms of the disease are most characteristic of the majority of patients with various forms of liver cirrhosis. • Pain in the region of the liver, in the epigastrium, or diffuse pain in the whole abdomen. • Dyspepsia. • Decreased work capacity, general weakness, fatigue. • Fever is usually irregular and sometimes of the undulant type. • A hemorrhagic syndrome. • Cachexia; • Jaundice often attended by skin itching.

48. Data of physical examination:

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

50. Ascites • The liver is enlarged, firm, the surface is sometimes irregular, and the lower edge sharp. • Enlargement of the spleen is often attended by its increased activity (hypersplenism).