Timely prevention of this pathology, which has social and economic significance on a national scale, is one of priority problems integrated approach, which also includes osteopathic correction of dysfunctions of the hepatobiliary system. An osteopath (chiropractor), using soft visceral techniques, improves the functioning of the liver, gallbladder and bile ducts, thereby normalizing the qualitative composition of bile and its further passage in the body.
(Gallstone disease) is a disease caused by the formation of stones in the gall bladder or bile ducts, as well as possible violation patency of the ducts due to stone blockage. In Europe and America, over the age of 50 years, about 1/3 of women and about 1/4 of men suffer from cholelithiasis. There is a clear connection between prevalence and gender.
The left and right hepatic ducts, when merging at the point of exit from the liver lobes, form the common hepatic duct (3-4 cm long). The common bile duct is located lateral to the common hepatic artery and anterior to the portal vein.
A duct opens into the duodenum at the papilla of Vater.
The sphincter of Oddi of the common bile duct is located at the site where the duct passes through the ampulla of the papilla of Vater; regulates the flow of bile into the duodenum.
The intrahepatic ducts receive blood directly from the hepatic arteries;
The blood supply to the supraduodenal part of the common bile duct is variable. In most cases, blood flow is directed away from the porta hepatis. The most significant vessels lie along the edges of the bile duct at 3 and 5 o'clock. Gallbladder located in the vesical fossa on bottom surface liver. It serves as a landmark for the border of the right lobe of the liver.
Anatomical parts of the gallbladder: bottom, body, Hartmann's pouch (located between the neck and body of the gallbladder - the part of the bladder located posteriorly). The wall of the gallbladder consists of smooth muscle cells and connective tissue. The lumen is lined with tall columnar epithelium.
Arterial blood enters the gallbladder through the gallbladder artery, a branch of the right hepatic artery (less commonly the hepatic artery itself); venous outflow from the gallbladder occurs mainly through the cystic vein, which flows into the portal vein. Lymph from the gallbladder flows both to the liver and to the lymph nodes gate of the liver. The cystic duct, common hepatic duct and cystic artery form Calot's triangle. The bile ducts have sphincters that regulate bile secretion: Lütkens' sphincter in the neck of the gallbladder, Mirisi's sphincter at the confluence of the cystic and common bile ducts.
Education gallstones occurs in the gallbladder as a result of the deposition of dense particles of bile. Most of the stones (70%) consist of cholesterol, bilirubin and calcium salts. Stagnation of bile, increase in the concentration of bile salts. Stagnation of bile is promoted by pregnancy, sedentary lifestyle, hypomotor dyskinesia biliary tract, low-fat food. An important factor is inflammation; inflammatory exudate contains large number protein and calcium salts. Protein can become the core of the stone, and calcium, combined with bilirubin, forms the final appearance of the stone.
Cholesterol gallbladder stones: Most gallbladder stones form cholesterol by settling from supersaturated bile (especially at night, when the concentration in the gallbladder is highest). In women, the risk of developing gallstones is increased by the use of oral contraceptives, rapid weight loss, and the presence of diabetes mellitus, resection ileum. Cholesterol stones are large, with a smooth surface, yellow, often lighter than water and bile. Ultrasound reveals the symptom of floating stones.
Pigmented gallbladder stones, composed predominantly of calcium bilirubinate, are found in patients with chronic hemolysis (eg, sickle cell anemia or spherocytosis). Infection of bile with microorganisms that synthesize beta-glucuronidase also contributes to the formation of pigment stones, as it leads to an increase in the content of direct (unbound) bilirubin in the bile. Pigment stones have a smooth surface and are green or black in color.
Salt mixed stones (consisting of calcium bilirubinate) are more often formed against the background of inflammation of the biliary tract.
Calcium, combined with free bilirubin, settles in the form of stones (calcium salt of bilirubin). Normally, bile contains a glucuronidase antagonist, which prevents the formation of stones. When the gallbladder contracts, the stones migrate. Obstruction of the cystic duct with a stone leads to shutdown of the gallbladder and the occurrence of obstructive cholecystitis and hydrocele of the gallbladder.
Gallstone disease is a symptom complex that includes not only the formation of stones, but also the presence of typical biliary colic. The pathogenesis of the latter is the advancement of the stone, spasm and obstruction of the bile ducts. Stones located in the area of the bottom and body of the gallbladder usually do not appear clinically, i.e. are “mute” - 25-35% of people of both sexes after 65 years are such “carriers”.
Biliary colic is a syndrome characterized by sudden onset sharp pains in the right hypochondrium, radiating to the right clavicle, in right hand, in the back, accompanied by nausea and vomiting. There may be bile in the vomit, hence the feeling of extreme bitterness in the mouth. With prolonged pain and obstruction, itching of the skin develops and jaundice appears a little later. Symptoms of peritoneal irritation are possible.
When the cystic duct is blocked, an inflammatory process and hydrocele of the gallbladder may develop. In the presence of inflammation, cholangitis and cholangiohepatitis may develop; if obstruction is incomplete, secondary biliary cirrhosis liver. When a stone is retained in the common bile duct, obstruction of the pancreatic duct is also possible with the formation of acute pancreatitis, including those associated with the reflux of bile into the pancreas.
When examining a patient, an enlarged gallbladder can be detected, but it may also be wrinkled and there may be practically no contents in it. As a rule, such patients have an enlarged liver, it is soft and painful on palpation.
A number of symptoms are characteristic. Ortner's symptom: pain when tapping along the edge of the right costal arch. Murphy's sign: increased pain when pressing on the abdominal wall in the projection of the gallbladder during a deep breath. Kehr's symptom: the same on palpation at the point of the gallbladder (in the angle formed by the costal arch and the edge of the rectus abdominis muscle.). Zakharyin's symptom: the same with tapping at the point of intersection of the right rectus abdominis muscle with the costal arch. Mussy's symptom: pain when pressing between the legs of the right sternocleidomastoid muscle (phrenicus symptom is caused by irradiation of pain along the phrenic nerve, which is involved in the innervation of the liver capsule and gall bladder). Beckmann's sign: pain in the right supraorbital area. Yosh's sign: the same at the occipital point on the right. Mayo-Robson sign: pain when pressing in the area of the costovertebral angle.
Stones are identified by x-ray and ultrasonic methods research. Cholecystography, intravenous cholegraphy, and radionuclide scanning of the gallbladder are used.
If a tumor is suspected, with obstructive jaundice unknown origin, concomitant liver damage -aphy, laparoscopy and laparoscopic cholecystocholangiography. Laboratory tests: high level bilirubin, increased bile acids, signs of an inflammatory process in the blood. If the common bile duct is completely blocked, there is no urobilin in the urine, and a sharp increase in the secretion of bile acids is possible.
Osteopathic correction of dysfunctions of the liver, gallbladder and bile ducts is one of the non-drug methods treatment. Thanks to many years of experience, the hands of an osteopath (chiropractor) are able to detect the most subtle anomalies in the location and tension of these organs and their ligamentous apparatus. An osteopathic session includes not only diagnosis, treatment and testing of identified dysfunctions in the hepatobiliary system, but also the general integration of this system into the physiological rhythms of the body. Which leads to the restoration of the excretory activity of the liver and gall bladder with the normalization of bile passage.
Conservative treatment is aimed at dissolving stones. If stones were discovered by chance and do not bother the patient, most experts are inclined to believe that no active measures should be taken. drug treatment. The patient is explained the main provisions of his eating behavior and diet, which will slow down the process of formation of new stones or their increase, and will also reduce the likelihood of biliary colic - the main clinical manifestation cholelithiasis.
The general principle of diet therapy is frequent split meals (up to 5-6 times a day), at the same hours, taking into account individual tolerance products. Eating large amounts of food in the evening and at night is contraindicated. Energy value food 2500-2900 kcal/day, its content of proteins, fats, carbohydrates and vitamins should be balanced.
It is important to reduce (even eliminate) the proportion of animal fats in the diet and increase plant fats. The latter are more easily emulsified by bile, which facilitates the process of digestion and absorption of fats into small intestine. Besides, vegetable fat stimulates metabolism in liver cells (hepatocytes), increasing the volume of bile they produce and reducing its lithogenicity.
Among products containing animal protein, preference should be given to lean meats (beef, poultry, rabbit, fish). Increasing the consumption of plant fiber (bran, vegetables (pumpkin, beets, various types cabbage, watermelon, etc.) and fruits (apricot, plum, persimmon, etc.). Sufficient (at least 2 liters) fluid intake, especially alkaline mineral water(without gas), also recommended for patients with cholelithiasis.
Products whose consumption should be sharply limited and even excluded include spicy foods, seasonings, fried, fatty, smoked foods, dough products, especially rich ones, meat and fish broths, carbonated and cold drinks, nuts, creams. Products containing large amounts of cholesterol (liver, brains, egg yolks, lamb and beef fats, etc.) are also contraindicated.
intrahepatic ducts receive blood directly from the hepatic arteries;
The blood supply to the supraduodenal part of the common bile duct is variable. In most cases, blood flow is directed away from the porta hepatis. The most significant vessels lie along the edges of the bile duct at 3 and 5 o'clock.
The gallbladder is located in the vesicular fossa on the undersurface of the liver. It serves as a landmark for the border of the right lobe of the liver.
Anatomical parts of the gallbladder: bottom, body, Hartmann's pouch (located between the neck and body of the gallbladder - the part of the bladder located posteriorly).
The wall of the gallbladder consists of smooth muscle cells and connective tissue. The lumen is lined with tall columnar epithelium.
arterial blood enters the gallbladder through the gallbladder artery, a branch of the right hepatic artery (less commonly the hepatic artery itself);
venous outflow from the gall bladder occurs primarily through the cystic vein, which flows into the portal vein.
Lymph from the gallbladder flows both to the liver and to the lymph nodes of the porta hepatis.
The cystic duct, common hepatic duct and cystic artery form Calot's triangle. The bile ducts have sphincters that regulate bile secretion: Lütkens' sphincter in the neck of the gallbladder, Mirisi's sphincter at the confluence of the cystic and common bile ducts.
motor innervation is carried out through fibers of the vagus nerve and postganglionic fibers from the celiac ganglia. The level of preganglionic sympathetic innervation is Th8-Th9.
Sensitive innervation is carried out by sympathetic fibers from the root ganglia at the level of Th8-Th9
Heister valves are folds of the mucous membrane of the cystic duct. Despite their name, they do not have valve functions.
Gallbladder, vesica biliaris, is a thin-walled hollow organ for the accumulation and concentration of bile, which periodically enters after contraction and relaxation of the gallbladder wall and relaxation of the closures [sphincters]. In addition, the gallbladder regulates and maintains a constant level of bile pressure in the bile ducts. It is pear-shaped and is located on the visceral surface of the liver in its own fossa, fossa vesicae felleae on the lower surface of the liver. Here, with the help of connective tissue, it fuses tightly with the fossa of the bladder. Gallbladder from the side abdominal cavity covered with peritoneum. The length of the gallbladder is from 8 to 14 cm, width - 3-5 cm; content - 40-70 cm3. In the gallbladder there is a fundus, fundus vesicae biliaris; neck, collum vesicae biliaris; and body, corpus vesicae biliaris. The neck of the gallbladder passes into the cystic duct, ductus cysticus. The wall of the gallbladder consists of three layers: mucous, tunica mucosa, muscle, tunica muscularis, and adventitia, tunica adventitia.
Mucous membrane, tunica mucosa, the gallbladder is thin and forms numerous folds; it is lined with high prismatic epithelium with a striped border. In the neck area it forms several spiral folds, plicae spirales (Heisteri). The nuchal-tubular glands are located in the submucosa of the bladder neck.
Muscularis, tunica muscularis, gallbladder is formed by one circular layer smooth muscles, which stand out significantly in the cervical area and directly pass into the muscular layer of the cystic duct. In the area of the bladder neck, the muscle elements form the closure [Lutkens sphincter].
The adventitia, tunica adventitia, is built of dense fibrous connective tissue; it contains many thick elastic fibers that form networks.
The gallbladder is a reservoir in which bile accumulates. It is located in the fossa of the gallbladder on the visceral surface of the liver and is pear-shaped. Its blind extended end is the bottom of the gallbladder, comes out from under bottom edge liver at the level of the junction of the cartilages 8I and 9 of the right ribs, which corresponds to the intersection of the right edge of the rectus abdominis muscle with the right costal arch. The narrower end of the bladder, directed towards the gate of the liver, is called the neck of the gallbladder. Between the bottom and the neck is the body of the gallbladder. The neck of the bladder continues into the cystic duct, which merges with the common hepatic duct. The volume of the gallbladder ranges from 30 to 50 cubic cm, its length is 8-12 cm, and its width is 4-5 cm.
The structure of the gallbladder wall resembles the intestinal wall. The free surface of the gallbladder is covered with peritoneum, which passes onto it from the surface of the liver, and forms a serous membrane. In those places where the serous membrane is absent, outer shell The gallbladder is represented by adventitia. The muscular layer consists of smooth muscle cells.
The mucous membrane forms folds, and in the neck of the bladder and in the cystic duct it forms a spiral fold.
The common bile duct is located between the layers of the hepatoduodenal ligament, to the right of the common hepatic artery and anterior to the portal vein. The duct goes down first behind the upper part of the duodenum, and then between its descending part and the head of the pancreas, pierces the medial wall of the descending part of the duodenum and opens at the apex major papilla duodenum, having previously connected with the pancreatic duct. After the merging of these ducts, an extension is formed - the hepatic-pancreatic ampulla, which has at its mouth the sphincter of the hepatic-pancreatic ampulla, or sphincter of the ampullae. Before merging with the pancreatic duct, the common bile duct has a common bile duct sphincter in its wall, which blocks the flow of bile from the liver and gallbladder into the lumen of the duodenum (into the hepatopancreatic ampulla).
Bile produced by the liver accumulates in the gallbladder, entering there through the cystic duct from the common hepatic duct. The exit of bile into the duodenum is closed at this time due to contraction of the sphincter of the common bile duct. Bile enters the duodenum from the liver and gall bladder as needed (when food gruel passes into the intestine).
The gallbladder artery (and the proper hepatic artery) approaches the gallbladder. Venous blood flows through the vein of the same name into the portal vein. Innervation is carried out by branches of the vagus nerves and from the hepatic sympathetic plexus.
For X-ray examination of the gallbladder, a radiopaque substance is injected intravenously. This substance is secreted into the bile in the blood, accumulates in the gallbladder and forms a shadow on the radiograph, projected at the level of 1-11 lumbar vertebrae.
The gallbladder is one of the auxiliary unpaired organs. However, in its absence, the duodenum takes over the function of accumulating bile.
The gallbladder is an elongated, hollow, muscular sac that stores bile produced by the liver. Located under the liver, the gallbladder controls the flow of bile into the duodenum. Bile and bile pigments play an important role in the breakdown and absorption of fats. It is not an essential organ and is often removed with surgical procedure, known as cholecystectomy in cases of gallbladder disease or when present.
The gallbladder is a pear-shaped organ that is approximately 7 to 10 centimeters in length and 2 to 3 cm in width. It has the ability to accumulate about 50 milliliters of bile inside itself, which can be released, if necessary, through the small bile duct (gallbladder channel) into the common bile duct. From here, bile enters the lumen of the duodenum. Usually this process is interconnected with the digestion process. The release of bile is carried out under the control of the autonomic nervous system in response to receiving a signal about the arrival of food. Therefore, often when used fatty foods increased bile formation occurs and the person feels the movement of bile. This is just a response to a stimulus.
The wall of the gallbladder consists of several layers, including the epithelium ( inner layer), mucous membrane, muscular frame and serosa (outer layer).
The gallbladder consists of 3 parts - the fundus, the body and the neck. The fundus protrudes from under the liver and is the part visible from the front that can be examined using ultrasound diagnostics. The body is the main expanded part that lies between the fundus and the cystic duct. The neck of the gallbladder is the narrow part that passes into the cystic duct.
The cystic duct is about 3 to 4 centimeters in length and transports bile into the common bile duct.
The arterial blood supply to the gallbladder is through the portal artery, which arises from the right hepatic artery. Venous drainage occurs through the bile vein - this mainly accounts for the drainage venous blood from the cervix and cystic duct. Venous drainage of the body and bottom of the gallbladder is carried out directly with the participation of the visceral surface of the liver and through the hepatic sinusoids. Lymphatic fluid drains into cystic lymph nodes, which are located next to the liver and have access to the abdominal lymph nodes.
Innervation is carried out through:
These nerve endings regulate contraction of the gallbladder, relaxation of the corresponding sphincters and provoke pain syndrome for diseases.
The gallbladder is located in the right hypochondrium, below the visceral surface of the liver. This organ is interconnected with the liver using thin connective tissue. Therefore any inflammatory processes it quickly spreads to the liver parenchyma. The gallbladder is located in the right upper quadrant of the abdominal cavity. The bottom of this organ protrudes anteriorly from lower limit liver. It is located slightly to the right of the location of the duodenum. Has exits to colon and duodenum.
The main functions of the gallbladder relate to the storage and secretion of bile.
1. Accumulation and storage of bile. This organ is also capable of causing an increase in the concentration of bile coming from the liver, so that a large volume of bile can be stored in a small space (1 liter of bile can be concentrated in a volume of 50 ml).
