Diseases of the bile ducts. What symptoms indicate that the bile ducts are clogged? Cystic duct


The bile ducts are a complex transport route for liver secretions. They go from the reservoir (gallbladder) into the intestinal cavity.

The bile ducts are an important transport route for liver secretions, ensuring its outflow from the gallbladder and liver to the duodenum. They have their own special structure and physiology. Diseases can affect not only the gallbladder itself, but also the bile ducts. There are many disorders that impair their functioning, but modern monitoring methods make it possible to diagnose diseases and treat them.

The bile duct is a collection of tubular tubules through which bile is evacuated into the duodenum from the gallbladder. Regulation of the work of muscle fibers in the walls of the ducts occurs under the influence of impulses from the nerve plexus located in the liver area (right hypochondrium). The physiology of excitation of the bile ducts is simple: when the receptors of the duodenum are irritated by food masses, nerve cells send signals to the nerve fibers. From them, a contraction impulse is sent to the muscle cells, and the muscles of the bile ducts relax.

The movement of secretions in the bile ducts occurs under the influence of pressure exerted by the lobes of the liver - this is facilitated by the function of the sphincters, called motor, GB and tonic tension of the vascular walls. The large hepatic artery feeds the tissues of the bile ducts, and the outflow of oxygen-poor blood occurs into the portal vein system.

Anatomy of the bile ducts

The anatomy of the biliary tract is quite confusing, because these tubular formations are small in size, but gradually they merge, forming large canals. Depending on how the bile capillaries are located, they are divided into extrahepatic (hepatic, common bile and cystic duct) and intrahepatic.

The beginning of the cystic duct is located at the base of the gallbladder, which, like a reservoir, stores excess secretions, then merges with the hepatic duct, forming a common channel. The cystic duct emerging from the gallbladder is divided into four sections: supraduodenal, retropancreatic, retroduodenal and intramural canals. Coming out at the base of the papilla of Vater of the duodenum, a section of a large bile vessel forms an orifice, where the channels of the liver and pancreas are transformed into the hepatic-pancreatic ampulla, from which a mixed secretion is released.

The hepatic duct is formed by the fusion of two side branches that transport bile from each part of the liver. The cystic and hepatic tubules will flow into one large vessel - the common bile duct (choledochus).

Major duodenal papilla

Speaking about the structure of the biliary tract, one cannot help but recall the small structure into which they flow. The major duodenal papilla (DC) or papilla of Vater is a hemispherical flattened elevation located on the edge of the fold of the mucous layer in the lower part of the DP, 10–14 cm above it there is a large gastric sphincter - the pylorus.

The dimensions of the Vater nipple range from 2 mm to 1.8–1.9 cm in height and 2–3 cm in width. This structure is formed when the biliary and pancreatic excretory ducts merge (in 20% of cases they may not connect and the ducts leaving the pancreas open a little higher).


An important element of the major duodenal papilla is, which regulates the flow of mixed secretions from bile and pancreatic juice into the intestinal cavity, and it also prevents intestinal contents from entering the biliary tract or pancreatic canals.

Pathologies of the bile ducts

There are many disorders of the functioning of the biliary tract; they can occur separately or the disease will affect the gallbladder and its ducts. The main violations include the following:

  • blockage of bile ducts (cholelithiasis);
  • dyskinesia;
  • cholangitis;
  • cholecystitis;
  • neoplasms (cholangiocarcinoma).

The hepatocyte secretes bile, which consists of water, dissolved bile acids, and some metabolic waste products. If this secretion is removed from the reservoir in a timely manner, everything functions normally. If there is stagnation or too rapid secretion, bile acids begin to interact with minerals, bilirubin, creating deposits - stones. This problem is typical for the bladder and bile ducts. Large stones clog the lumen of the bile vessels, damaging them, which causes inflammation and severe pain.

Dyskinesia is a dysfunction of the motor fibers of the bile ducts, in which there is an abrupt change in the pressure of secretions on the walls of blood vessels and the gallbladder. This condition can be an independent disease (of neurotic or anatomical origin) or accompanies other disorders, such as inflammation. Dyskinesia is characterized by the appearance of pain in the right hypochondrium several hours after eating, nausea, and sometimes vomiting.

– inflammation of the walls of the biliary tract, may be a separate disorder or a symptom of other disorders, for example, cholecystitis. The inflammatory process in the patient manifests itself as fever, chills, profuse secretion of sweat, pain in the right hypochondrium, lack of appetite, and nausea.


- an inflammatory process involving the bladder and bile duct. The pathology is of infectious origin. The disease occurs in an acute form, and if the patient does not receive timely and high-quality therapy, it becomes chronic. Sometimes, with permanent cholecystitis, it is necessary to remove the gallbladder and part of its ducts, because the pathology prevents the patient from living a normal life.

Neoplasms in the gallbladder and bile ducts (most often they occur in the common bile duct area) are a dangerous problem, especially when it comes to malignant tumors. Drug treatment is rarely carried out; the main therapy is surgery.

Methods for studying the bile ducts

Methods for diagnostic examination of the biliary tract help to detect functional disorders, as well as track the appearance of neoplasms on the walls of blood vessels. The main diagnostic methods include the following:

  • duodenal intubation;
  • intraoperative choledo- or cholangioscopy.

An ultrasound examination can detect deposits in the gallbladder and ducts, and also indicates neoplasms in their walls.

– a method for diagnosing the composition of bile, in which the patient is parenterally administered an irritant that stimulates contraction of the gallbladder. The method allows you to detect deviations in the composition of liver secretions, as well as the presence of infectious agents in it.

The structure of the ducts depends on the location of the liver lobes; the general plan resembles the branched crown of a tree, since many small ones flow into large vessels.

The bile ducts are the transport route for liver secretions from its reservoir (gallbladder) into the intestinal cavity.

There are a lot of diseases that disrupt the functioning of the biliary tract, but modern research methods make it possible to detect the problem and cure it.

– a mechanical obstacle to the movement of bile from the liver and gallbladder into the duodenum. Develops against the background of cholelithiasis, tumor and inflammatory diseases of the biliary tract, strictures and scars of the common bile duct. Symptoms of the pathology are pain in the right hypochondrium, jaundice, acholic stool and dark urine, and a significant increase in the level of bilirubin in the blood. The diagnosis is made based on studies of biochemical blood samples, RP, ultrasound, MRI and CT of the abdominal organs. Treatment is usually surgical - endoscopic, laparoscopic or extended surgery is possible.

General information

Blockage of the bile ducts is a dangerous complication of various diseases of the digestive system, which leads to the development of obstructive jaundice. The most common cause of blocked bile ducts is gallstone disease, affecting up to 20% of people. According to the observations of specialists in the field of gastroenterology and abdominal surgery, women suffer from cholelithiasis three times more often than men.

Difficulty in the outflow of bile from the liver and gallbladder is accompanied by the gradual development of the clinical picture of subhepatic (obstructive) jaundice. Acute blockage of the biliary tract can develop immediately after an attack of biliary colic, but this is almost always preceded by symptoms of inflammation of the biliary tract. Failure to provide timely assistance to a patient with bile duct blockage can lead to the development of liver failure and even death of the patient.

Causes

Obstruction of the bile ducts can be caused either by blockage from the inside or compression from the outside. A mechanical obstruction to the outflow of bile can be complete or partial; the severity of the clinical manifestations depends on the degree of obstruction. There are a number of diseases that can impair the passage of bile from the liver to the duodenum. Blockage of the ducts is possible if the patient has: stones and bile duct cysts; cholangitis or cholecystitis; scars and ductal strictures.

The pathogenesis of blockage of the bile ducts is multicomponent; the inflammatory process in the bile ducts usually begins. Inflammation leads to thickening of the mucosa and narrowing of the lumen of the ducts. If at this moment a calculus enters the ducts, it cannot leave the common bile duct on its own and causes complete or partial closure of its lumen. Bile begins to accumulate in the bile ducts, causing them to expand. From the liver, bile can first enter the gallbladder, significantly stretching it and causing an exacerbation of the symptoms of cholecystitis.

If there are stones in the gallbladder, they can enter the cystic duct and block its lumen. In the absence of bile outflow through the cystic duct, empyema or hydrocele of the gallbladder may develop. An unfavorable prognostic sign for blockage of the bile ducts is the secretion of whitish mucus (white bile) from the common bile duct mucosa - this indicates the onset of irreversible changes in the bile ducts. Bile retention in the intrahepatic ducts leads to the destruction of hepatocytes and the release of bile acids and bilirubin into the bloodstream.

Active direct bilirubin, not bound to blood proteins, enters the blood, causing significant damage to the cells and tissues of the body. Bile acids contained in bile facilitate the absorption and metabolism of fats in the body. If bile does not enter the intestines, the absorption of fat-soluble vitamins A, D, E, K is impaired. Because of this, the patient develops hypoprothrombinemia, blood clotting disorders, and other symptoms of hypovitaminosis. Further stagnation of bile in the intrahepatic tract leads to significant damage to the liver parenchyma and the development of liver failure.

Symptoms

Symptoms of bile duct blockage usually appear gradually; acute onset is quite rare. Typically, the development of clinical biliary obstruction is preceded by a biliary tract infection. The patient complains of fever, weight loss, and cramping pain in the right hypochondrium. The skin becomes jaundiced, and the patient is bothered by itching of the skin. The lack of bile acids in the intestines leads to discoloration of stool, and increased excretion of direct bilirubin by the kidneys leads to the appearance of dark-colored urine. With partial blockage, alternation of discolored portions of feces with colored ones is possible.

Complications

Against the background of destruction of hepatocytes, all liver functions are disrupted, and acute liver failure develops. First of all, the detoxification activity of the liver suffers, which is manifested by weakness, increased fatigue, and gradual disruption of the functioning of other organs and systems (lungs, heart, kidneys, brain). If the patient does not receive help before this stage of the disease, the prognosis is extremely unfavorable. In the absence of timely surgical treatment of the pathology, the patient may develop sepsis, bilirubin encephalopathy, and cirrhosis of the liver.

Diagnostics

The initial manifestations of blockage of the bile ducts resemble symptoms of cholecystitis or biliary colic, with which the patient can be hospitalized in the gastroenterology department. Preliminary diagnosis is carried out using such a simple and safe method as ultrasonography of the pancreas and biliary tract. If biliary tract stones, dilatation of the common bile duct and intrahepatic bile ducts are detected, MR pancreatocholangiography and CT scan of the biliary tract may be required to clarify the diagnosis.

To clarify the cause of obstructive jaundice, the location of the stone, the degree of blockage of the bile ducts, percutaneous transhepatic cholangiography and dynamic scintigraphy of the hepatobiliary system are performed. They make it possible to detect disturbances in the dynamics of bile, its outflow from the liver and gallbladder. The most informative diagnostic method is retrograde cholangiopancreatography. This technique includes simultaneous endoscopic and x-ray examination of the biliary tract. If stones are detected in the lumen of the duct during this procedure, stones can be extracted from the common bile duct. If there is a tumor compressing the bile duct, a biopsy is taken.

Biochemical liver tests show increased levels of direct bilirubin, alkaline phosphatase, transaminases, amylase and blood lipase. Prothrombin time is prolonged. A general blood test may reveal leukocytosis with a shift of the leukocyte formula to the left, a decrease in the level of red blood cells and platelets. The coprogram contains a significant amount of fat and no bile acids.

Treatment of blocked bile ducts

All patients require consultation with an abdominal surgeon. After all examinations have been carried out, the location and degree of obstruction have been determined, the tactics of surgical treatment are determined. If the patient's condition is severe, it may be necessary to transfer him to the intensive care unit for antibacterial, infusion and detoxification therapy.

Until the patient's condition is stabilized, extensive surgery can be dangerous, so non-invasive methods are used to facilitate the outflow of bile. These include extraction of bile duct stones and nasobiliary drainage during RPCG (through a probe inserted above the site of narrowing of the bile ducts), percutaneous puncture of the gallbladder, cholecystostomy and choledochostomy. If the patient's condition does not improve, a more complex intervention may be required: percutaneous transhepatic drainage of the bile ducts.

After the patient’s condition returns to normal, the use of endoscopic treatment methods is recommended. During endoscopy, dilation (endoscopic bougienage) of the biliary tract is carried out in case of cicatricial stenosis and tumor strictures, and a special plastic or mesh tube is inserted into the biliary tract to preserve their lumen (endoscopic stenting of the common bile duct). If a scar-narrowed duodenal papilla is obstructed by a calculus, endoscopic balloon dilatation of the sphincter of Oddi may be required.

If stones and other obstructions to the outflow of bile cannot be removed endoscopically, an extended operation is required. During such a surgical intervention, the common bile duct is opened (choledochotomy), so in the future it is necessary to prevent the leakage of bile through the sutures of the bile duct into the abdominal cavity. To do this, external drainage of the bile ducts is performed according to Kehr (with a T-shaped tube), and after cholecystectomy - external drainage of the bile ducts according to Halsted (with a polyvinyl chloride catheter inserted into the stump of the cystic duct).

Prognosis and prevention

The prognosis for timely provision of medical care is favorable. Cancerous obstruction of the common bile duct significantly worsens the course of the disease and the results of treatment. Prevention consists of the treatment of chronic inflammatory diseases of the hepatobiliary system, cholelithiasis. It is recommended to maintain a healthy lifestyle, proper nutrition with the exception of fatty, fried and extractive foods.


The biliary tract is a complex biliary system that includes intrahepatic and extrahepatic bile ducts and the gallbladder.

Intrahepatic bile ducts- intercellular bile canaliculi, intralobular and interlobular bile ducts (Fig. 1.7, 1.8). Bile excretion begins with intercellular bile canaliculi(sometimes called bile capillaries). Intercellular bile canaliculi do not have their own wall; it is replaced by indentations on the cytoplasmic membranes of hepatocytes. The lumen of the bile canaliculi is formed by the outer surface of the apical (capalicular) part of the cytoplasmic membrane of adjacent hepatocytes and tight contact complexes located at the points of contact of hepatocytes. Each liver cell participates in the formation of several bile canaliculi. Tight junctions between hepatocytes separate the lumen of the bile canaliculi from the circulatory system of the liver. Violation of the integrity of tight junctions is accompanied by regurgitation of canalicular bile into the sinusoids. Intralobular bile ducts (cholangioles) are formed from intercellular bile canaliculi. Having passed through the border plate, the cholangioles in the periportal zone merge into the periportal bile ducts. At the periphery of the hepatic lobules, they merge into the bile ducts themselves, from which interlobular ducts of the first order are subsequently formed, then of the second order, and large intrahepatic ducts are formed that leave the liver. When leaving the lobule, the ducts expand and form an ampulla, or intermediate duct of Hering. In this area, the bile ducts are in close contact with blood and lymphatic vessels, and therefore the so-called hepatogenic intrahepatic cholangiolitis can develop.

Intrahepatic ducts from the left, quadrate and caudate lobes of the liver form the left hepatic duct. The intrahepatic ducts of the right lobe merge with each other to form the right hepatic duct.

Extrahepatic bile ducts consist of a system of ducts and a reservoir for bile - the gallbladder (Fig. 1.9). The right and left hepatic ducts form the common hepatic duct, into which the cystic duct flows. The length of the common hepatic duct is 2-6 cm, diameter 3-7 mm.

The topography of the extrahepatic bile ducts is variable. There are many options for connecting the cystic duct to the common bile duct, as well as additional hepatic ducts and options for their entry into the gallbladder or common bile duct, which must be taken into account during diagnostic studies and during operations on the bile duct (Fig. 1.10).

The confluence of the common hepatic and cystic ducts is considered the upper limit common bile duct(its extramural part), which enters the duodenum (its intramural part) and ends with the large duodenal papilla on the mucous membrane. In the common bile duct, it is customary to distinguish the supraduodenal part, located above the duodenum; retroduodenal, passing behind the upper part of the intestine; retropancreatic, located behind the head of the pancreas; intrapancreatic, passing through the pancreas; intramural, where the duct enters obliquely through the posterior wall of the descending duodenum (see Fig. 1.9 and Fig. 1.11). The length of the common bile duct is about 6-8 cm, diameter is 3-6 mm.

In the deep layers of the wall and submucosa of the terminal part of the common bile duct there are glands (see Fig. 1.9) that produce mucus, which can cause adenomas and polyps.

The structure of the terminal section of the common bile duct is very variable. In most cases (55-90%), the mouths of the common bile and pancreatic ducts merge into the common duct, forming an ampulla (V-shaped version), where bile and pancreatic juice are mixed (Fig. 1.12). In 4-30% of cases, there is a separate flow of ducts into the duodenum with the formation of independent papillae. In 6-8% of cases they merge high (Fig. 1.13), which creates conditions for biliary-pancreatic and pancreatobiliary reflux. In 33% of cases, the fusion of both ducts in the area of ​​the major duodenal papilla occurs without the formation of a common ampulla.

The common bile duct, merging with the pancreatic duct, pierces the posterior wall of the duodenum and opens into its lumen at the end of the longitudinal fold of the mucous membrane, the so-called major duodenal papilla, called the papilla of Vater. In approximately 20% of cases, 3-4 cm proximal to the papilla of Vater on the mucous membrane of the duodenum, you can see the accessory duct of the pancreas - the minor duodenal papilla (papilla duodeni minor, s. Santorini) (Fig. 1.14). It is smaller and not always functioning. According to T. Kamisawa et al., the patency of the accessory pancreatic duct at 411 ERCPs was 43%. The clinical significance of the accessory pancreatic duct is that when its patency is preserved, pancreatitis is less likely to develop (in patients with acute pancreatitis, the duct functions only in 17% of cases). With a high pancreatobiliary junction, conditions are created for the reflux of pancreatic juice into the biliary tree, which contributes to the development of the inflammatory process, malignant tumors and the so-called enzymatic cholecystitis. With a functioning accessory pancreatic duct, the incidence of carcinogenesis is lower, since reflux of pancreatic juice from the bile ducts can be reduced due to its entry into the duodenum through the accessory duct.

The formation of biliary pathology can be influenced by peripapillary diverticula, the frequency of which is about 10-12%; they are risk factors for the formation of gallstones, bile ducts, create certain difficulties in performing ERCP, papillosphincterotomy, and are often complicated by bleeding during endoscopic manipulations in this area.

Gallbladder- a small hollow organ, the main functions of which are the accumulation and concentration of liver bile and its evacuation during the digestion process. The gallbladder is located in a depression on the visceral surface of the liver between the quadrate and right lobes. The size and shape of the gallbladder are highly variable. Usually it has a pear-shaped, less often conical shape. The projection of the gallbladder onto the surface of the body is shown in Fig. 1.15.

The upper wall of the gallbladder is adjacent to the surface of the liver and is separated from it by loose connective tissue, the lower wall faces the free abdominal cavity and is adjacent to the pyloric part of the stomach, duodenum and transverse colon (see Fig. 1.11), which causes the formation of various anastomoses with adjacent organs, for example, with a bedsore of the wall of the gallbladder, which developed from the pressure of a large immovable stone. Sometimes gallbladder located intrahepatically or is completely outside the liver. In the latter case, the gallbladder is covered on all sides by visceral peritoneum, has its own mesentery, and is easily movable. A mobile gallbladder is more prone to torsion and stones easily form in it.

The length of the gallbladder is 5-10 cm or more, and the width is 2-4 cm. The gallbladder has 3 sections: the bottom, the body and the neck (see Fig. 1.9). The widest part of it is the bottom; it is this part of the gallbladder that can be palpated during obstruction of the common bile duct (Courvoisier's symptom). The body of the gallbladder passes into the neck - its narrowest part. In humans, the neck of the gallbladder ends in a blind sac (Hartmann's pouch). The cervix has a spiral-shaped fold of Keister, which can complicate the evacuation of biliary sludge and small gallstones, as well as their fragments after lithotripsy.

Typically, the cystic duct arises from the superolateral surface of the cervix and flows into the common bile duct 2-6 cm beyond the confluence of the right and left hepatic ducts. There are various options for its flow into the common bile duct (Fig. 1.16). In 20% of cases, the cystic duct does not immediately connect to the common bile duct, but is located parallel to it in the common connective tissue membrane. In some cases, the cystic duct wraps around the common bile duct in front or behind. One of the features of their connection is the high or low confluence of the cystic duct into the common bile duct. Variants of the connection of the gallbladder and bile ducts on cholangiograms are about 10%, which must be taken into account during cholecystectomy, since incomplete removal of the gallbladder leads to the formation of the so-called long stump syndrome.

The thickness of the gallbladder wall is 2-3 mm, the volume is 30-70 ml; if there is an obstacle to the outflow of bile along the common bile duct, the volume in the absence of adhesions in the bladder can reach 100 and even 200 ml.

The bile ducts are equipped with a complex sphincter apparatus that operates in a clearly coordinated manner. There are 3 groups of sphincters. At the confluence of the cystic and common bile ducts there are bundles of longitudinal and circular muscles that form the Mirizzi sphincter. When it contracts, the flow of bile through the duct stops, and at the same time the sphincter prevents the retrograde flow of bile when the gallbladder contracts. However, not all researchers recognize the presence of this sphincter. In the area of ​​​​the transition between the neck of the gallbladder and the cystic duct, the spiral-shaped sphincter of Lutkens is located. In the terminal section, the common bile duct is covered by three layers of muscles that form the sphincter of Oddu, named after Ruggero Oddi (1864-1937). The sphincter of Oddi is a heterogeneous formation. It distinguishes between clusters of muscle fibers surrounding the extra- and intramural part of the duct. The fibers of the intramural region partially pass onto the ampulla. Another muscle sphincter at the end of the common bile duct surrounds the large duodenal papilla (papilla sphincter). The muscles of the duodenum approach it, bending around it. An independent sphincter is a muscular formation surrounding the terminal part of the pancreatic duct.

Thus, if the common bile and pancreatic ducts merge together, then the sphincter of Oddi consists of three muscle formations: the sphincter of the common bile duct, which regulates the flow of bile into the ampulla of the duct; the sphincter of the papilla, which regulates the flow of bile and pancreatic juice into the duodenum, protecting the ducts from reflux from the intestine, and, finally, the sphincter of the pancreatic duct, which controls the exit of pancreatic juice (Fig. 1.17).

In the mucous membrane of the duodenum, this anatomical formation is defined as a hemispherical, cone-shaped or flattened elevation (Fig. 1.18, A, B) and is designated as the major duodenal papilla, the major duodenal papilla, the papilla of Vater: lat. papilla duodeni major. Named after the German anatomist Abraham Vater (1684-1751). The size of the papilla of Vater at the base is up to 1 cm, height - from 2 mm to 1.5 cm, located at the end of the longitudinal fold of the mucous membrane in the middle of the descending part of the duodenum, approximately 12-14 cm distal to the pylorus.

When the sphincter apparatus is dysfunctional, the outflow of bile is disrupted, and in the presence of other factors (vomiting, duodenal dyskinesia), pancreatic juice and intestinal contents can enter the common bile duct with the subsequent development of inflammation in the ductal system.

The length of the intramural part of the common bile duct is about 15 mm. In this regard, to reduce the number of complications after endoscopic papillotomy, it is necessary to make a 13-15 mm incision in the upper sector of the major duodenal papilla.

Histological structure. The wall of the gallbladder consists of mucous, muscular and connective tissue (fibromuscular) membranes, the lower wall is covered with a serous membrane (Fig. 1.19), and the upper one does not have it, it is adjacent to the liver (Fig. 1.20).

The main structural and functional element of the gallbladder wall is the mucous membrane. On macroscopic examination of an opened bladder, the inner surface of the mucous membrane has a fine-mesh appearance. The average diameter of irregularly shaped cells is 4-6 mm. Their boundaries are formed by gentle low folds 0.5-1 mm high, which flatten and disappear when the bladder fills, i.e. are not a stationary anatomical formation (Fig. 1.21). The mucous membrane forms numerous folds, due to which the bladder can significantly increase its volume. There is no submucosa or muscularis propria in the mucous membrane.

The thin fibromuscular membrane is represented by irregularly located smooth muscle bundles mixed with a certain amount of collagen and elastic fibers (see Fig. 1.19, Fig. 1.20). The bundles of smooth muscle cells of the bottom and body of the bladder are located in two thin layers at an angle to each other, and in the neck area circularly. Transverse sections of the gallbladder wall show that 30-50% of the area occupied by smooth muscle fibers is represented by loose connective tissue. This structure is functionally justified, since when the bladder is filled with bile, connective tissue layers with a large number of elastic fibers are stretched, which protects the muscle fibers from overstretching and damage.

In the depressions between the folds of the mucous membrane there are crypts or Rokitansky-Aschoff sinuses, which are branched invaginates of the mucous membrane, penetrating through the muscular layer of the gallbladder wall (Fig. 1.22). This feature of the anatomical structure of the mucous membrane contributes to the development of acute cholecystitis or gangrene of the gallbladder wall, stagnation of bile or the formation of microliths or calculi in them (Fig. 1.23). Despite the fact that the first description of these structural elements of the gallbladder wall was made by K. Rokitansky in 1842 and supplemented in 1905 by L. Aschoff, the physiological significance of these formations has only recently been assessed. In particular, they are one of the pathognomonic acoustic symptoms of adenomyomatosis of the gallbladder. The wall of the gallbladder contains Lushka's moves- blind pockets, often branched, sometimes reaching the serous membrane. Microbes can accumulate in them and cause inflammation. When the mouth of Luschka's passages narrows, intramural abscesses can form. When removing the gallbladder, these passages in some cases can be the cause of bile leakage in the early postoperative period.

The surface of the mucous membrane of the gallbladder is covered with high prismatic epithelium. On the apical surface of epithelial cells there are numerous microvilli that form an absorptive border. In the cervical area there are alveolar tubular glands that produce mucus. Enzymes found in epithelial cells are β-glucuronidase and esterase. Using a histochemical study, it was established that the mucous membrane of the gallbladder produces carbohydrate-containing protein, and the cytoplasm of epithelial cells contains mucoproteins.

Bile duct wall consists of mucous, muscular (fibromuscular) and serous membranes. Their severity and thickness increase in the distal direction. The mucous membrane of the extrahepatic bile ducts is covered with a single-layer high prismatic epithelium. It has many mucous glands. In this regard, the ductal epithelium can perform both secretion and resorption and synthesize immunoglobulins. The surface of the bile ducts is smooth over a large extent; in the distal part of the common duct it forms pocket-like folds, which in some cases make it difficult to probe the duct from the duodenum.

The presence of muscle and elastic fibers in the wall of the ducts ensures their significant expansion during biliary hypertension, compensates for bile outflow even with a mechanical obstruction, for example, with choledocholithiasis or the presence of putty-like bile in it, without clinical symptoms of obstructive jaundice.

A feature of the smooth muscles of the sphincter of Oddi is that its myocytes, compared to the muscle cells of the gallbladder, contain more γ-actin than α-actin. Moreover, the actin of the sphincter of Oddi muscles is more similar to the actin of the longitudinal muscular layer of the intestine than, for example, to the actin of the muscles of the lower esophageal sphincter.

The outer shell of the ducts is formed by loose connective tissue in which vessels and nerves are located.

The gallbladder is supplied with blood by the cystic artery. This is a large tortuous branch of the hepatic artery, which has a different anatomical location. In 85-90% of cases it arises from the right branch of the own hepatic artery. Less commonly, the cystic artery originates from the common hepatic artery. The cystic artery usually crosses the hepatic duct posteriorly. The characteristic arrangement of the cystic artery, cystic and hepatic ducts forms the so-called Calot triangle.

As a rule, the cystic artery has a single trunk, less often it splits into two arteries. Considering the fact that this artery is terminal and can undergo atherosclerotic changes with age, in elderly people in the presence of an inflammatory process in the gallbladder wall, the risk of necrosis and perforation increases significantly. Smaller blood vessels penetrate the wall of the gallbladder from the liver through its bed.

Gallbladder veins are formed from intramural venous plexuses, forming the cystic vein, which flows into portal vein.

Lymphatic system. There are three networks of lymphatic capillaries in the gallbladder: in the mucous membrane under the epithelium, in the muscular and serous membranes. The lymphatic vessels formed from them form the subserosal lymphatic plexus, which anastomoses with the lymphatic vessels of the liver. The outflow of lymph is carried out into the lymph nodes located around the neck of the gallbladder, and then into the lymph nodes located at the porta hepatis and along the common bile duct. Subsequently, they connect with lymphatic vessels that drain lymph from the head of the pancreas. Enlarged lymph nodes when they are inflamed ( pericholedocheal lymphadenitis) can cause obstructive jaundice.

Innervation of the gallbladder carried out from the hepatic nerve plexus, formed by branches of the celiac plexus, anterior vagus trunk, phrenic nerves and gastric nerve plexus. Sensitive innervation is carried out by nerve fibers V-XII of the thoracic and I-II lumbar segments of the spinal cord. In the wall of the gallbladder, three first plexuses are distinguished: submucosal, intermuscular and subserosal. With chronic inflammatory processes in the gallbladder, degeneration of the nervous system occurs, which underlies chronic pain syndrome and dysfunction of the gallbladder. The innervation of the biliary tract, pancreas and duodenum has a common origin, which determines their close functional relationship and explains the similarity of clinical symptoms. The gallbladder, cystic and common bile ducts contain nerve plexuses and ganglia similar to those in the duodenum.

Blood supply to the biliary tract carried out by numerous small arteries originating from the proper hepatic artery and its branches. The outflow of blood from the wall of the ducts goes into the portal vein.

Lymphatic drainage occurs through lymphatic vessels located along the ducts. The close connection between the lymphatic ducts of the bile ducts, gallbladder, liver and pancreas plays a role in metastasis in malignant lesions of these organs.

Innervation carried out by branches of the hepatic nerve plexus and interorgan communication like local reflex arcs between the extrahepatic bile ducts and other digestive organs.

Anatomy

What is the danger of blocked ducts?

Diagnosis of diseases

Features of treatment

Therapeutic diet

ethnoscience

Dear readers, the bile ducts (bile tract) perform one important function - they conduct bile to the intestines, which plays a key role in digestion. If for some reason it periodically does not reach the duodenum, there is a direct threat to the pancreas. After all, bile in our body eliminates the properties of pepsin that are dangerous for this organ. It also emulsifies fats. Cholesterol and bilirubin are excreted through bile because they cannot be fully filtered by the kidneys.

If the gallbladder ducts are blocked, the entire digestive tract suffers. Acute blockage causes colic, which can result in peritonitis and urgent surgery; partial obstruction impairs the functionality of the liver, pancreas and other important organs.

Let's talk about what is special about the bile ducts of the liver and gallbladder, why they begin to conduct bile poorly and what needs to be done to avoid the adverse consequences of such blockage.

The anatomy of the bile ducts is quite complex. But it is important to understand it in order to understand how the biliary tract functions. Bile ducts are intrahepatic and extrahepatic. On the inside, they have several epithelial layers, the glands of which secrete mucus. The bile duct has a biliary microbiota - a separate layer that forms a community of microbes that prevent the spread of infection in the organs of the biliary system.

The intrahepatic bile ducts have a tree-like structure. The capillaries pass into the segmental bile ducts, which, in turn, flow into the lobar ducts, which form the common hepatic duct outside the liver. It enters the cystic duct, which drains bile from the gallbladder and forms the common bile duct (choledochus).

Before entering the duodenum, the common bile duct passes into the pancreatic excretory duct, where they unite into the hepatopancreatic ampulla, which is separated from the duodenum by the sphincter of Oddi.

Diseases that cause obstruction of the bile ducts

Diseases of the liver and gallbladder in one way or another affect the condition of the entire biliary system and cause blockage of the bile ducts or their pathological expansion as a result of a chronic inflammatory process and stagnation of bile. Obstruction is provoked by diseases such as cholelithiasis, cholecystitis, kinks in the gallbladder, the presence of structures and scars. In this condition, the patient needs urgent medical attention.

Blockage of the bile ducts is caused by the following diseases:

  • bile duct cysts;
  • cholangitis, cholecystitis;
  • benign and malignant tumors of the pancreas and organs of the hepatobiliary system;
  • scars and strictures of the ducts;
  • cholelithiasis;
  • pancreatitis;
  • hepatitis and cirrhosis of the liver;
  • helminthic infestations;
  • enlarged lymph nodes of the hepatic hilum;
  • surgical interventions on the biliary tract.

Most diseases of the biliary system cause chronic inflammation of the biliary tract. It leads to thickening of the mucosal walls and narrowing of the lumen of the ductal system. If, against the background of such changes, a stone enters the gallbladder duct, the stone partially or completely blocks the lumen.

Bile stagnates in the bile ducts, causing them to expand and aggravating the symptoms of the inflammatory process. This can lead to empyema or hydrocele of the gallbladder. For a long time, a person tolerates minor symptoms of blockage, but eventually irreversible changes in the bile duct mucosa will begin to occur.

Why is it dangerous?

If the bile ducts are clogged, you need to contact a specialist as soon as possible. Otherwise, there will be an almost complete loss of the liver from participating in detoxification and digestive processes. If the patency of the extrahepatic or intrahepatic bile ducts is not restored in time, liver failure may occur, which is accompanied by damage to the central nervous system, intoxication and turns into a severe coma.

Blockage of the bile ducts can occur immediately after an attack of biliary colic https://site/zhelchnaya-kolika against the background of movement of stones. Sometimes obstruction occurs without any preliminary symptoms. The chronic inflammatory process, which inevitably occurs with dyskinesia of the bile ducts, cholelithiasis, cholecystitis, leads to pathological changes in the structure and functionality of the entire biliary system.

In this case, the bile ducts are dilated and may contain small stones. Bile stops flowing into the duodenum at the right time and in the required volume.

Emulsification of fats slows down, metabolism is disrupted, the enzymatic activity of the pancreas decreases, food begins to rot and ferment. Stagnation of bile in the intrahepatic ducts causes the death of hepatocytes - liver cells. Bile acids and direct active bilirubin begin to enter the bloodstream, which provokes damage to internal organs. The absorption of fat-soluble vitamins against the background of insufficient flow of bile into the intestines worsens, and this leads to hypovitaminosis and dysfunction of the blood coagulation system.

If a large stone gets stuck in the bile duct, it immediately closes its lumen. Acute symptoms occur that signal the severe consequences of biliary obstruction.

How does blocked duct manifest itself?

Many of you probably think that if the bile ducts are clogged, the symptoms will immediately be so acute that you will not be able to tolerate them. In fact, the clinical manifestations of blockage may increase gradually. Many of us have experienced discomfort in the area of ​​the right hypochondrium, which sometimes even lasts for several days. But we do not rush to specialists with these symptoms. And such aching pain may indicate that the bile ducts are inflamed or even clogged with stones.

As ductal patency worsens, additional symptoms appear:

  • acute girdling pain in the right hypochondrium and abdomen;
  • yellowing of the skin, the appearance of obstructive jaundice;
  • discoloration of feces due to a lack of bile acids in the intestines;
  • itching of the skin;
  • darkening of urine due to active excretion of direct bilirubin through the kidney filter;
  • severe physical weakness, increased fatigue.

Pay attention to symptoms of obstruction of the bile ducts and diseases of the biliary system. If you undergo diagnostics at the initial stage and change your diet, you can avoid dangerous complications and maintain the functionality of the liver and pancreas.

Diseases of the biliary system are treated by gastroenterologists or hepatologists. You should contact these specialists if you have complaints of pain in the right hypochondrium and other characteristic symptoms. The main method for diagnosing diseases of the bile ducts is ultrasound. It is recommended to look at the pancreas, liver, gall bladder and ducts.

If a specialist detects strictures, tumors, dilatation of the common bile duct and ductal system, the following studies will be additionally prescribed:

  • MRI of the bile ducts and the entire biliary system;
  • biopsy of suspicious areas and tumors;
  • feces for coprogram (low bile acid content is detected);
  • blood biochemistry (increased direct bilirubin, alkaline phosphatase, lipase, amylase and transaminases).

Blood and urine tests are prescribed in any case. In addition to the characteristic changes in the biochemical study, when the ducts are obstructed, the prothrombin time is prolonged, leukocytosis with a shift to the left is observed, and the number of platelets and red blood cells decreases.

Features of treatment

Treatment tactics for bile duct pathologies depend on concomitant diseases and the degree of blockage of the lumen of the duct system. In the acute period, antibiotics are prescribed and detoxification is carried out. In this condition, serious surgical interventions are contraindicated. Experts try to limit themselves to minimally invasive treatment methods.

These include the following:

  • choledocholithotomy - an operation for partial excision of the common bile duct in order to free it from stones;
  • stenting of the bile ducts (installation of a metal stent that restores duct patency);
  • drainage of the bile ducts by installing a catheter into the bile ducts under endoscopic control.

After restoration of patency of the ductal system, specialists can plan more serious surgical interventions. Sometimes blockage is caused by benign and malignant neoplasms, which have to be removed, often together with the gallbladder (with calculous cholecystitis).

Total resection is performed using microsurgical instruments under endoscopic control. Doctors remove the gallbladder through small punctures, so the operation is not accompanied by heavy blood loss and a long rehabilitation period.

During cholecystectomy, the surgeon must assess the patency of the ductal system. If stones or strictures remain in the bile ducts after the bladder is removed, severe pain and emergencies may occur in the postoperative period.

Removing a bladder clogged with stones in a certain way saves other organs from destruction. And ducts too.

You should not refuse surgery if it is necessary and threatens the entire biliary system. The entire digestive tract and immune system suffer from stagnation of bile, inflammation, and the proliferation of infectious pathogens.

Often, against the background of ductal diseases, a person begins to lose weight sharply and feel unwell. He is forced to limit his activity and give up his favorite job, because constant pain attacks and health problems do not allow him to live a full life. And the operation in this case prevents the dangerous consequences of chronic inflammation and bile stagnation, including malignant tumors.

Therapeutic diet

For any diseases of the bile ducts, diet No. 5 is prescribed. This involves eliminating fatty, fried foods, alcohol, carbonated drinks, and dishes that cause gas formation. The main goal of such nutrition is to reduce the increased load on the biliary system and prevent the sharp flow of bile.

In the absence of severe pain, you can eat as usual, but only if you have not abused prohibited foods before. Try to completely avoid trans fats, fried foods, spicy foods, smoked foods, and processed foods. But at the same time, nutrition should be complete and varied. It is important to eat often, but in small portions.

ethnoscience

It is necessary to resort to treatment with folk remedies when the bile ducts are clogged with extreme caution. Many herbal recipes have a strong choleretic effect. By using such methods, you risk your own health. Since it is impossible to clean the bile ducts with herbal mixtures without the risk of developing colic, you should not experiment with herbs at home.

First, make sure there are no large stones that could cause blockage of the duct system. If you use choleretic herbs, give preference to those that have a mild effect: chamomile, rose hips, flax seeds, immortelle. Please consult your doctor first and perform an ultrasound. You should not joke with choleretic compounds if there is a high risk of blockage of the bile ducts.

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This video describes a method of gentle cleansing of the gallbladder and ducts that can be used at home.

When the ducts become clogged, the flow of bile is disrupted. A number of pathologies of the biliary system lead to this. When the bile ducts are clogged, the symptoms do not differ from the standard signs of biliary system disorders. Diagnosis is carried out based on the results of general analyzes and mechanical studies. If the bile ducts are clogged, then the main symptoms are pain in the right side of the body, yellowness of the skin and changes in the shades of feces and urine.

When the bile ducts are clogged, the symptoms do not differ from the standard signs of biliary system disorders

What is a blocked bile duct

Obstruction or blockage of the biliary tract is a serious complication of a number of pathologies of the gastrointestinal tract, which causes obstructive jaundice. Gallstone disease is the main disease leading to obstruction of the common bile ducts. When the common bile ducts are dilated, the digestive system works normally. Obstruction or blockage of the bile ducts is much more common in women. Therefore, for the purpose of prevention, the female part of the population needs to know what it is. Impaired release of bile from organs is accompanied by the formation of a clinical picture of subhepatic jaundice. An acute manifestation of the complication can occur immediately after an outbreak of colic, but usually signs of inflammation of the common bile ducts appear in advance. Failure to receive medical care in such a situation can lead to liver failure and even death.

Symptoms of blockage

Symptoms of common bile duct blockage may appear and progress gradually, but in rare cases the disease may begin acutely. Often, even before the first signs appear, inflammation of the bile ducts occurs.

Obstruction of the biliary tract is characterized by the following manifestations:

  • pain in the abdomen or right side of the body;
  • skin itching;
  • weight loss;
  • temperature increase.

One of the symptoms of blockage of the common passages is an increase in temperature to 39 degrees

When the bile ducts are blocked, pain is one of the main symptoms. It is characterized by such parameters as: paroxysmal, cramping, intensity, localization in the right side of the body, irradiation to the right half of the neck, right collarbone and shoulder.

The temperature is influenced by the level of bile pressure on the walls of the canals and bladder and the intensity of the inflammatory process. Temperatures can even reach 39 degrees Celsius.

As a result of the destruction of cells in the liver, all functions of the organ are disrupted, after which acute liver failure soon develops - complete failure of the organ. First of all, the process of neutralizing toxic substances is disrupted. This is indicated by the following:

  • high fatigue;
  • frequent weakness;
  • loss of performance;
  • disruptions in the functioning of the heart, kidneys, brain and lungs.

The formation of these signs after blockage of the common bile ducts has occurred means a poor prognosis. Once the liver fails to detoxify toxic substances, coma or death is rarely avoided. Therefore, it is extremely important to take emergency therapeutic measures before the detoxification function is lost.

Causes

Bile ducts and ducts can be blocked either from the inside or narrowed as a result of external pressure. A mechanical obstruction to the movement of bile affects the severity of medical manifestations.

Risk factors for the development of complications may include obesity, dystrophy, stomach trauma, infections of the biliary tract, pancreas and biliary system, and malfunction of the immune system.

Diagnostics

Blockage and narrowing of the bile ducts requires timely and accurate diagnosis. The main thing in the diagnostic procedure is to establish the root cause of the pathology. For this purpose, there are a number of diagnostic methods suitable for a particular patient, depending on his age and well-being.

Whether there is obstruction of the bile ducts can be determined in the following ways:

Whether there is obstruction of the common passages, computed tomography will help determine

  • gastrodudenoscopy, required for visual examination of the condition of the inner surface of the wall of the stomach and duodenum;
  • general urine tests;
  • CT scan;
  • a blood test showing the presence of an inflammatory process in the bile ducts (the number of leukocytes exceeds the norm);
  • Magnetic resonance imaging;
  • cholecystography, based on X-rays and contrast, through which the condition and anomalies of the diseased organ can be assessed;
  • magnetic resonance cholangiopancreatography:;
  • choleretic ultrasound (after eating two raw yolks on an empty stomach), used to study the working capacity and contractility of the organ; endoscopic retrograde cholangiopancreatography, aimed at examining the inner surface of the canals;
  • cholangiography, which helps to recognize pathology by introducing contrast into the bloodstream;
  • duodenal probing, used for a full assessment of bile;
  • conventional ultrasound of internal organs for a general analysis of the state of the bile duct system.

After passing the diagnosis, the diagnosis is established by the doctor and he also prescribes a suitable course of therapy.

Treatment

Stones removed from the bladder are destroyed using an endoscope during a special procedure

Treatment of bile ducts and ducts consists in getting rid of blockages and destroying the obstruction. The stones removed from the bladder are destroyed using an endoscope during a special procedure.

In individual cases, obstruction requires surgery or even removal of the bladder. After surgery, treatment is based on a course of antibiotics.

Obstruction and narrowing of the bile ducts resulting from tumor formations are treated with endoscopic therapy. The most common methods of treating the complication in question are:

  1. Cholecystectomy.
  2. Sphincterotomy.
  3. Endoscopic retrograde cholangiopancreatography.

Drug therapy

Treatment of duct obstruction is based on the use of drugs from the group of antispasmodics: “Platifilin”, “Drotaverine”, “Promedol”, “Papaverine”, “Baralgin”, “Atrapin” and “No-shpa”.

Standard therapy includes the following tablets:

  1. Choleretic (Holosas; Urolisan; Hologol; Berbirina bisulfate; Flomin, Allochol).
  2. Painkillers and anti-inflammatory drugs: (Analgin; Ketorolac; Paracetamol; Metamizole; Ibuprofen; Tempalgin, Ursafalk).
  3. Antibiotics.

ethnoscience

Folk choleretic decoctions include:

A decoction of lemon juice is a popular choleretic remedy.

  • an infusion of apple cider vinegar mixed with apple juice in a ratio of 1 tablespoon of vinegar to 1 glass of juice;
  • a decoction of 4 tablespoons of lemon juice mixed with a glass of plain water;
  • infusion of dried mint leaves;
  • a mixture of juice of 1 beet, 4 carrots and 1 cucumber.

Prevention

Pathology is often a consequence of insufficient physical activity. An excellent preventive measure is moderate physical activity - walking, morning exercises, cycling, swimming.

Stones in the ducts can be resolved by consuming medications, foods or herbs with a choleretic function - corn leaves, birch leaves, agrimony.

Increasing the amount of fiber and reducing sugar and saturated fats in the diet will help to avoid dangerous blockage of the common bile ducts.

Doctors say that avoiding stressful situations, maintaining a healthy lifestyle, maintaining a healthy diet and getting rid of bad habits will help prevent the risk.

Video

Blockage of the bile duct with a stone. Complication after blockage. What to do?

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