ГоловнаЗворотній зв'язок

Гастроэнтерология (анг,рус)

TREATMENT OF GALLSTONES

 

 

 

 

 

 

n            Asymptomatic gallstones found incidentally are not usually treated because the majority will never give symptoms.

n            Symptomatic gallstones are best treated surgically. Cholecystectomy is the therapy of choice for symptomatic gallstone disease and acute cholecystitis. Laparoscopic cholecystectomy compares favorably with the open procedure, with lower morbidity, shorter hospital stay, and better cosmetic results.

n            Minimal access techniques have largely replaced non-surgical treatment. Gallstones can be dissolved and fragmented in the gallbladder or removed mechanically from the common bile duct.

 

Medical dissolution

n            Medical dissolution of gallstones can be achieved by oral administration of the bile acid ursodeoxycholic acid.

n            Ursodeoxycholic acid (8 - 10 mg/kg/d PO in two to three divided doses for prolonged periods) might be prudent in a small select group of patients with small cholesterol stones in normally functioning gallbladders who are at high risk for complications from surgical therapy. Side effects include diarrhea and reversible elevation in serum transaminase levels.

n            Ursodeoxycholic acid (UDCA) is one of the secondary bile acids, which are metabolic byproducts of intestinal bacteria.

n            Primary bile acids are produced by the liver and stored in the gall bladder. When secreted into the colon, primary bile acids can be metabolized into secondary bile acids by intestinal bacteria.

n            Primary and secondary bile acids help the body digest fats.

n            Ursodeoxycholic acid helps regulate cholesterol by reducing the rate at which the intestine absorbs cholesterol molecules while breaking up micelles containing cholesterol.

n             Because of this property, ursodeoxycholic acid is used to treat (cholesterol) gallstones non-surgically.

n            Ursodeoxycholic acid goes by the trade names Actigall, Ursofalk, Urso, and Urso Forte.

 

Percutaneous cholecystotomy

n            Percutaneous cholecystotomy and decompression of the gallbladder can be performed under fluoroscopy in severely ill patients with acute cholecystitis who are not surgical candidates.

Extracorporeal shock-wave lithotripsy

n            Extracorporeal shock-wave lithotripsy is expensive and not widely available.

n            Bile salt therapy is necessary following lithotripsy to dissolve the gallstone fragments within the gallbladder.

n            As in the case of oral bile salt therapy, only 30% of all patients with gallbladder disease are suitable for lithotripsy.

Contact dissolution therapy.

n            This procedure involves injecting a drug directly into the gallbladder to dissolve cholesterol stones.

n            The drug (methyl tert-butyl ether)  can dissolve some stones in 1 to 3 days, but it causes irritation and some complications have been reported.

n            The procedure is being tested in symptomatic patients with small stones.

Supportive measures

n            Supportive measures include fluid resuscitation and broad-spectrum antimicrobial agents, especially in the event of complications such as acute cholecystitis with sepsis, perforation, peritonitis, abscess, or empyema formation.

n            All therapeutic regimens which retain the gallbladder have a 50% recurrence of stones after 5 years.

 

BILIARY MOTOR DISORDERS

n            Some patients with right upper quadrant discomfort do not have gallstones and the term 'biliary dyskinesia' has been introduced to describe this condition.

n            The dyskinetic disorder may affect either the gallbladder or the sphincter of Oddi.

n             Patients complain of recurrent epigastric or right upper quadrant pain.

n            The diagnosis is established by excluding gallstones and undertaking tests to demonstrate that contraction of the gallbladder is associated with pain and abnormal liver analytes or that the papilla is stenosed.

n            ERCP, endoscopic manometry and radiomanometry are all used in an attempt to define this disorder more clearly.

n             Identification of biliary dyskinesia remains difficult and the treatment is uncertain. Some patients with evidence of sphincter dysfunction derive benefit from sphincterotomy.

 

 

 

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