Diagnosis of hepatitis, cholecystitis, liver cirrhosis.

1. Diagnosis of hepatitis, cholecystitis, liver cirrhosis.

2. Chronic hepatitis - polyetiological chronic liver inflammatory-destructive nature with moderate fibrosis and preserved lobular structure, lasting more than 6 months.

3. Etiology: the onset and progression of infectious and noninfectious nature is crucial defective immune response to damage liver tissue. Hepatitis viral, toxic and alcoholic lesions developed not only as a result of damages which the agent, but also as a result of an immune reaction cell type against hepatocytes. Damage liver hepatotoxic viruses emerging area of immune cytolysis of hepatocytes in which the virus persists and there are its markers - surface antigens of viruses. Induces immune cytolysis: antibodies fixed on the surface of hepatocytes exhibit a cytotoxic effect and induce cytotoxic T-lymphocytes against liver cells. At the same cells transformed with K-cells (killer), sensitized to hepatocytes caused by migration of cells formed inflammatory infiltrate, composed in viral hepatitis include lymphocytes, macrophages, fibroblasts.

4. Clinicalmanifestationsofhepatitisandcirrhosisoftheliver: Asthenicsyndrome.Asthenicphenomenaaccompanymostliverdiseasesareoftenthefirstsignsofillness. Characterizedbyweakness, decreasedperformance, increasedfatigue, lossofpreviousinterestsreductioninitiatives. Changingemotionalbackgroundof the man - depressedmood, depression, irritabilityepisodes

5. Diarrheal syndrome Dyspeptic symptoms, early signs of liver damage.Dry and bitter taste in the mouth - most often met symptoms. Nausea, vomiting, belching. Discomfort right subcostal area - a characteristic feature. The equivalent symptom is a feeling of heaviness in the epigastrium, constant bloating. Decreased appetite combined with intolerance of many products. Constipation particularly pronounced in portal hypertension.Diarrhea alternating with constipation. There slimming down to cachexia.

6. Abdominalpain. Themosteasyoption - a feelingofheaviness, pressureintheupperabdomen. Monotonepainintherightupperquadrantduetostretchingofthefibrousmembraneoftheliver, mostoftenappearaftereating.Paincanbelongorsharp. Sometimesthepainislocatedintherightsubcostal area , andunderthebreasts.

7. Cholestaticsyndrome.Manifestedpersistentorintermittentochrodermia, skinitching, darkurine, feceslightening. Vehetodystonicsyndrome.Psycho-emotional instability, insomnia, headache, cardialgia, fluctuationsinbloodpressure, sweating.

8. Febrile syndrome.Unexplained fever, prolonged or recurrent, most often seen in chronic active hepatitis, in the active stage of liver cirrhosis. The reason could be severe overgrowth of endogenous intoxication, periodic bacteremia. In 2/3 patients with cirrhosis due to fever associated infectious lesions - pneumonia, ascites - peritonitis.

9. Articular syndrome.Joint pain, prolonged or intermittent, without deformation accompanying reactive hepatitis and cirrhosis of the liver.

10. Hemorrhagicsyndrome.Bleedingfromthenoseandgums, subcutaneoushemorrhage, menorrhagia, bloodyvomiting, tarricexcrements. Edematous-ascitic syndrome.Fluidretention, increasingthesizeoftheabdomen, swellingofthelegs.Entsefalopatycsyndrome.Memoryloss, drowsiness, dyzoriyentationintimeandspace, inappropriatebehavior.

11. Etiology:viralalcoholicautoimmunetoxicdrug (toxic-allergic)nonspecificreactive Secondarybiliaryhepatitiswithhepaticcholestasisoutside II. Themorphologicalchanges:1. Persystic2. Lobular3. Activities:a) withmoderateactivity;  b) a highdegreeofactivity.4. Cholestatic Classification

12. III. Theclinicalcourse:Phaseof aggravationPhaseof remission IV. Forthefunctionalstateoftheliver:compensateddecompensated Classification

13. Physicalexamination:-Skin - greyish-pale, canbelocalordiffusehyperpigmentation (melasma). -Jaundice - developswhenhyperbilirubinemiaabove 30 mmol / l, expressedinbilirubinmorethan 120 mmol / l. -Originally jaundiceappearsonthepalateandsclera, sometimesthereisonlypartialochrodermianasolabialtriangle, forehead, palms. Itchingandtracessolutions,causedanincreaseintheskinofbileacids.-Teleangiectasia, or star-shapedangiomasontheneck, face, shoulders, back , racemes. Theirexpressionisreducedinthefallofbloodpressure, bleeding. Xanthoma - internallyyellowskinplaquesthatforminseverehyperlipidemia.

14. Hemorrhageintotheskin -pinpointhemorrhagesdevelopinprotractedcourseofhepatitis.Forchronicliverdiseasecharacterizedbypainlesssuperficialhemorrhagesintheskinandmucousmembranes, bleedingfromthegums, nose, uterinebleeding.Palmareritema (liverpalms) - symmetricsplotchyredpalmsandsoles. Spotsbecome palewith pressing andagainblushattheterminationofpressure. "Crimson, thecardinal'stongue" - andnosinergy ofpapillaeofthetonguetothedegreeof "patent" surface. Atrophyoftheshouldermusculatureduetoviolationofproteinmetabolismandhormonalimbalance.

15. Thereisthickeningofthedistalphalangesofthefingersofthetype "drumsticks“Gynecomastia -femaletypehaironthebodydevelopsas a resultofincreasedestrogenlevels. Possiblelossofpubichair, axillaryareas, testicularatrophy. Syndromemostoftenoccursinalcoholichepatitis. Legswelling, lymphadenopathy - arisesinseverehypoalbuminemia.

16. Enlargement of the liver - a characteristic sign of its parenchyma. Reducing the size of the liver is rare, in the later stages of cirrhosis of the liver is a bad prognostic sign. On palpation the liver during severe pathological process activity observed liver tenderness. Liver tissue is sealed, the edge can be condensed, the pointed, hilly. Splenomegaly is not typical for most cases of hepatitis

17. Diagnostictests. -Zag en. blood - anemia, leykopeniya. Acutealcoholichepatitisoccurswithleukocytosis, a sharpincreasein ESR, stabshift. -Tjtalurine test - a possiblemicrohematuria, mildproteinuria-biochem. ofblood - anincreaseof ALT and AST, hlutamatdehidrohenaze, lactatedehydrogenase, iron, vitamin B12, analkalinephosphataselinked (direct) bilirubin, totalbilirubin, cholesterol,reducedalbumin, protein, prothrombincomplex.-Sonography of liver: increasedinsize, increaseddensityheterogeneityof ehostruktures. -Radionuclide studyof liver. UsedradiopharmaceuticalBengalpinkforstudyofliverfunction.- Morphologicalstudyoftheliver - puncturesonbiopsy.

18. Treatmentdependsontheetiology, processactivityseverity. A duringacuteprocess.BedrestDiet 5Drugsthatimprovemetabolisminlivercells - ATP, Vit. B group, Glutamic acid.Hepatoprotectors: Essencialeforte, Gepabene, Sealyboron, Vitohepat.Glucocorticoids: Prednisolone, MethylPrednisolone (athighprocessactivity).Aminoquinolinedrugs: Delahil, Plakvenil, immunosuppressivedrugs: Azathioprine, Cyclosporine. whenviralhepatitis B, C, D - interferons α, β, γ. DetoxificationTherapy - Gemodez, Glucose, SodiumThiosulfate,enzymepreparations.Adsorbentsbileacids - Bilihnin, Cholestyramine, Activatedcarbonwithvitamins A, D, E, K, Enterodez, Ursofalk.Oxygentherapy, herbalmedicineBile - Yarrow, Immortelle, Hypericum, Rose, Dandelionroots.

19. Cirrhosis Thisis a progressive, diffuse, polyetiologicaldiseasecharacterizedby a significantdecreaseinthemassoffunctioninghepatocytes, fibrosiswithimpairedhepaticlobulestructureandvasculatureliver.

20. Etiology Alcoholic Virus (HBV, HVC, HBV + HDV) Primary biliary cirrhosis Secondary biliary cirrhosis Violation of venous outflow from the liver Metabolic Toxic Nutritional Cryptogenic Parasitic diseases Shunt surgery for intestinal

21. Diagnosis.Mainsymptomsandsyndromes: Astenovegetative, edematoussyndrome, endotoxemia, hyperbilirubinemia, diarrhea, intrahepaticcholestasis, portokavalnohobypass, hepatomegaly, splenomegaly, mesenchymal-inflammatory, cytolytic, bleeding, hepatocellularfailure, portalhypertension, malabsorption, anemia, hormonalimbalance.

22. Physical data • Resized and seal liver • Palpable spleen determined • Spider veins on the upper trunk and face • Palmar erythema • Gynecomastia and testicular atrophy • Veins on the anterior abdominal wall • Ascites • jaundice

23. Laboratory parameters • Hematologic: concentration of Hb, # of leukocytes and platelets, Coagulation, blood type, Rh factor, prothrombin index. • Biochemical: bilirubin, albumin, globulin, chloride, urea, creatinine, K, Na, copper, iron, Ig in the serum activity of ALT, AST, alkaline phosphatase. • Immunological indices serumHBsAg, anti-HVC, antibodies to smooth muscle, to soluble liver antigen, α-feto-protein.

24. Instrumental research • Esophagogastroduodenoscopy • Doppler-ultrasound liver • Computed tomography of the liver • Krizshkirna needle biopsy • Radioisotope scanning of the liver • Fluoroscopy esophagus and stomach

25. Treatment of cirrhosis • Regieme - dependingonthestageofcirrhosis. • Diet № 5 inportalhypertension - bezsoLevu, inhepaticcoma - Protein-free. • Detoxificationtherapy: Neogemodez, Glucose. • Anti-inflammatorytherapy: steroids, antibiotics, immunosuppressants, hepatoprotectors, adsorbentsbileacids, drugsthatimprovemetabolisminhepatocytes, pancreaticenzymes

26. "The main symptoms and syndromes in diseases of the hepato-biliary system. Methods of clinical, laboratory and instrumental examination. '

27. Chronic non-calculous (bilestone free) cholecystitis (sholecystitischronica) - a chronicinflammatorydisease. Polyetiologicalgallbladder, whichiscombinedwith motor-tonicdisorders (dyskinesia), biliarytractandchangesin physico-chemical propertiesandbiochemicalcompositionofbile (dysholia).

28. Etiology. Bacterialinfections Parasiticinfestation Duodenobiliarreflux Allergies Chronicinflammatorydiseaseofthedigestivesystem. Acutecholecystitis.

29. Predisposing factors Stagnationofbile. Reflexeffectsfromabdominalorgansduringdevelopmentintheiroverallprocess. Intestinaldysbiosis. Metabolicdisorderscontributingtochangesin physico-chemical propertiesandcompositionofbile (obesity, diabetes, gout). Hereditarywithrespectto XX.

30. The main pathogenic factors: Neurodegenerative changes ZHM wall. Neuroendocrine disorders. Stagnation and dysholiya bile. Violation of the wall ZHM. Factors:Allergic reactions and Immunoinflammatory.

31. Classification of chronic cholecystitis Etiology: kolibatcilic, enterokokcial, strepto-, stafilo-, pneumococcal, Salmonella, typhoid, dysentery, brutselozal, paratyphoidandothers. Thedegreeofseverity: mild, moderate, severe. Thenatureofthecourse: recurring, monotonous, intermittent. Duringphases: pointed, decreasingexacerbation,stableremission, unstableremission.Inthepresenceofcomplications, uncomplicated, complicatedperiholecistitis.

32. Clinical Subjective symptoms:-Pain at HBH localized in the area of ​​right hypochondrium, sometimes in the epigastrium, radiating to the right shoulder blade, sometimes - in the collarbone.-Dyspeptic symptoms:nausea, vomiting, a feeling of bitterness in the mouth, belching bitter. Due to the development of secondary gastritis, pancreatitis, enteritis appear heartburn, belching rotten, flatulence, loss of appetite, diarrhea.Itchy skin.-Fever.-Psycho-emotional disorders:depression, weakness, fatigue, irritability, emotional lability.

33. Physical examination. Review. Mostpatientssayoverweight.Insomepatientstheresubictericity ofsclerasandskin.Palpationmarkedtendernessintheregionofthegallbladder.Mayshowsomepositivesigns:SymptomZakharyin - painwhenpressingthepoint ZHM.S-mof Vasilenko - whentappedatthepoint ZHM attheheightofinspirationthereis a sharppain.S-m of Obraztsov-Murphy - afterclickingontheareaoffered ZHM patienttobreathe, whilethepatient "intercepts" breathofpaininthe ZHM.S-m of Ker - painonvdosiduringpalpationrighthypochondrium.S-m of Ortner - painwhentappedhishandontheedgeofrightcostalarch.S-m of Myusicardiology - painatthepointofthephrenicnerve (frenikus-symptom).

35. Pain point at disease gall  bladder:1 - cystic point2 - epigastric area3 - choledochitis-pancreatic area4 - zone in the area of ​​proc. acromion5 - point n. phrenici6 - spade point7 - point at the end of the 12th rib8 - point about 8 - 11 thoracic vertebrae9 - point to the right of 12 thoracic vertebrae

36. Laboratory and instrumental methods Total blood: moderate leukocytosis, left shift with increasing stab leukocytes, ESR acceleration. Biochemical analysis of blood: an exacerbation of increased content of sialic acids seromucoid, fibrin, alpha 2-globulin, possibly gamma globulin. Imunolohiche blood research: reduced number of B and T lymphocytes and IgA. Fractional duodenal intubation: Changes of duodenal intubation (portions "B"), typical of chronic cholecystitis:- The presence of large numbers of leukocytes, especially their clusters.- Detection by visual inspection bile pronounced turbidity, flakes of mucus.- Established in bile of a large number of cells columnar epithelium.- The appearance of cholesterol crystals and calcium bilirubinate.- Reduction of relative density and pH of gallbladder bile.- Changes in biochemical composition of bile (increased # of mucins substances reduced content of bile acids, cholate-cholesterol ratio, lipid complex)- Bacteriological study: the number of bacteria than 100,000 in 1 ml of bile.

37. 5. ultrasound: EchosignsofMts. cholecystitisZHM wallthickeninggreaterthan 2 mm;sealingwall, especiallywiththickening;unevennessanddeformationpathbladder, increaseordecreasethesize, adhesions;reductionorabsenceofmotion ZHM breathing;nonhomogenousecontent of "gallprecipitate."

38. Ultrasound of the liver and gall bladder

39. 6. Ro-study ZHM:Cholecystography:Signs HNH  - Impairedconcentrationabilityandmotorfunction ZHM (sharpslowdownemptying ZHM);  - ZHMdeformity (inequalitycontoursduepereholecystitis). 7. Computedtomography ZHM. 8. Radioisotopestudiesofbiliarytract:Symptoms: - persistentinfringementspeedfillingandemptying ZHM;increaseordecreaseitssize;seallying ZHM. 9. Thermography: observedlocaltemperatureincreaseof 0,3 -2 ° C, zone ZHM looksbright.

40. Cholelithiasis (CT scan) 1 - chronic cholecystitis(thickening of the walls of the gall bladder), 2 - calcium-containing stones in areaneck of the gallbladder

41. Treatment Inacutepatientlaxrecommendbedrestfor 7-10 days, 1-2 days a warmdrink. Diet № 5, frequentmeals (5-6 times / day)) insmallportions. Purchasingpainm anticholinergics: AtropineSulfate, Methacin, PlatifillinGidrotartrata, Gastrotsepin;antispasmodics: Papaverine, Nospanum;Analgesics: Proteins, Baralgin, Droperiodol. Antibiotictherapyinacute. Appointedwhenthinkingaboutthenatureofthebacterialdiseasehaveclinicalandlaboratorydataconfirmingtheactivityoftheinflammatoryprocessin ZHM (Erythromycin, Ampicillin, Oxacillin, Lincomycin, Furazolizon, Penicillin, Tetracycline, Blacks, Taryvid, Cephalosporinantibiotics). Detoxificationtherapyinverysevereexacerbationofsymptomsofintoxication: brothships, alkalinemineralwater / drip - gemodez, polidez, 5% glucoseisotonicdistrict.

42. 7. Bile means. Rational choice bile depends on the phase of chronic cholecystitis and concomitant type dyskinesia. 1) drugs that stimulate the formation of liver bile - Bile true (choleretic): preparations containing bile acids (Hologon, Deholin, Alahol, Festal, Holenzim, Liobil); synthetic choleretic (Nikodin, Tsykvalon, Oksafenamid); vegetable (Immortelle, Corn Silk, Flamini, Peppermint, Holosas, Parsley); hidroholiretyky (water type "NAFTA"); 2) drugs that stimulate bile (holekinetiki): Xylitol, Sorbitol, MgSO4, Tansy.

43. Normalization function of the autonomic NS: sedativ, minor tranquilizers. Immunomodulatory therapy: Timalin, T-aktyvhin, Sodium Nukleinat, Adaptogens (Ginseng, Pantocrinum, Siberian ginseng). Physiotherapy treatment. When stihanii acute phenomena - inductothermy, UHF, microwave, SMT, UST, electrophoresis of novocaine, MgSO4, applications paraffin wax, ORT, balneotherapy. Treatment of mineral water. Spa treatment in remission (TruskavetsGusyatin, Satan, Essentuki, Borjomi).

44. Chroniccalculouscholecystitis(sholecystitischronicacalculosa, cholelithiasis) - a diseasecharacterizedbytheformationofstonesinthegallbladder, atleast - inthebileducts.Inthedevelopmentofgallstonesareimportantmetabolicdisorders, infectionandbilestasis.Therearethreestagesofgallstonedisease.Thefirststage (physicalandchemical).Thesecondstage (latent) ischaracterizedbychangesinlithogenicbiletoformgallstones.Thethirdstageofcholelithiasis - clinical (calculouscholecystitis).

45. Clinical Subjective symptoms:  The most characteristic feature of the disease is a liver or biliary colic. Intense pain localized in the right upper quadrant and epigastric, radiating to the back, chest thing, right shoulder, shoulder, arm. Join nausea, repeated vomiting, which does not facilitate pain, bloating, delayed stool. With prolonged fit of itching appears. Physical examination.On examination can detect jaundice (the second day), xanthoma. There bloating, muscle tension and local tenderness in the right upper quadrant. Positive gall-mihurni symptoms and areas of hyperesthesia (lower angle shoulder, shoulder area, paravertebral right from VIII to IX thoracic vertebra).

46. Xanthelasma of the upper eyelid

47. LaboratoryandinstrumentalmethodsInthebiochemicalanalysisofbloodobservedincreaseincholesterollevels, increasingtheactivityofalkalinephosphatase.Ultrasound. Thesmallestsizeofstonesthatcandiagnose = 1-2 mm. Oftenunabletodeterminesediment (sand) in ZHM.Cholecystography. Stonesinthebileductsand ZHM seenas a zoneofenlightenment. Treatment.Firststage: dietnumber 5, eatlotsofvegetables, fruits, regularlyengageinphysicalactivity, obesitybeprevented.Secondstage: todissolvecholesterol (x-RAY negative) gallstonesprescribe (Henohol, Henofalk) andurodyzoksyholevoyi (Ursofalk, Urso - 100) acids.Inthethirdstageofthedisease, duringanattackofbiliouscolic, thepatientadmittedtothesurgicaldepartment. Assignantispasmodics, analgesics, ifnecessary - tooperate.

50. Cholangitis (angiocholitis - cholaengitis) - inflammationofthebileducts. Thereareacuteandchroniccholangitis. Chroniccholangitismaybelatent, recurrentandprolongedsepticcomponentofthecourse. ClinicalThefeelingofheavinessordullpainintherightupperquadrant, whichoccursinviolationdietbumpyride, physicalwork. Thepainspreadtotherightshoulderandshoulder.Diarrhealsyndrome: a bittertasteinthemouth, aversiontofattyfoods, nauseawheninhaledthesmellofthisdish.Itchingoftheskinthatcanoccurtolimitthearea.Astenodepresyvnyysyndrome: weakness.Longperiodsofunwarrantedsubfebrilewithperiodicfever. Whenviewedsubikterycmucous. Theyexhibit a largersoft, tenderliver.