1. Lecture: Surgical diseases of liver. Cholelithiais
Lecture: Surgical diseases of liver. Cholelithiais. Acute and chronic calculous cholecystitis. Portal hypertension. Etiology, pathogenesis, clinic diagnostic and treatment.
Author – reader R.Ya. Kushnir

2. Acute cholecystitis
Acute cholecystitis is inflammation of gall-bladder.

3. Acute cholecystitis

4. Classification Acute cholecystitis is divided into:
I. Acute calculous cholecystitis
II. Acute non-calculous cholecystitis
1. Catarrhal.
2. Phlegmonous.
3. Gangrenous.
4. Perforated.

5. Classification 5. Complicated: a) Hydropsy; b) Empyema;
c) Pancreatitis;
d) Icterus;

6. Classification e) Hepatitis; f) Cholangitis; g) Infiltrate;
h) Abscess;
i) Hepatic-kidney insufficiency;
j) Peritonitis (local, poured out, general).

7. Gangrenous cholecystitis

8. Symptoms
Murphy's symptoms is a delay of breathing during palpation of gall-bladder on inhalation.
Kehr's symptom is strengthening of pain at pressure on the area of gall-bladder, especially on deep inhalation.
Ortner's symptom — painfulness at the easy pattering on right costal arc by the edge of palm.

9. Symptoms
Mussy's symptom — painfulness at palpation between the legs (above a collar- bone) of right nodding muscle.
Blumberg's signs are the increases of painfulness at the rapid taking away of fingers by which a front abdominal wall is pressed on. This symptom is not pathognomic for cholecystitis but matters very much in diagnostics of peritonitis

10. Diagnosis program 1. Anamnesis and physical methods of inspection.
2. Survey sciagraphy of organs of abdominal cavity.
3. Sonography.
4. General analysis of blood and urine.

11. Diagnosis program 5. Diastase urines.
6. Biochemical blood test (bilirubin, amylase, alanine aminotransferase, asparaginase, alkaline phosphatase, remaining nitrogen, creatinine).
7. Coagulogram.

12. Conservative treatment
It must include:
1. Bed rest.
2. Hunger of 1–3 days, in the following table № 5 by Peuzner.
3. Cold on right hypochondrium.
4. Spasmolytics (sulfate of atropine, platyphyllin, papaverine, ni-shparum, baralgin).

13. Conservative treatment
5. Antibacterial therapy:
а) semisynthetic penicillin (ampicillin, oxacilline, ampiox);
б) cephalosporin (kefzol, klaforan);
в) nitrofurans (nitrofurantoin, furazolidon);
g) sulfanilamides (biseptol, ethazzole, norsulfazole).

14. Conservative treatment
6. Inhibitors of protease (contrical, trasilol, gordox, antagosan).
7. Desensitizing preparation (dimedrole, pipolphen, tavegile).
8. Disintoxication therapy (neohemodes, reopolyglucine).
9. Vitamins (С, В1, В6, В12 vitamins).

15. Indication to surgical treatment.
All forms of acute calculous cholecystitis, destructive and complicated forms of noncalculous cholecystitis (except for infiltrateу), and also acute catarrhal cholecystitis conservative treatment of which was uneffective are subject to surgical treatment.

16. Chronic cholecystitis
Inflammation of gall-bladder, that gained protracted chronic character, is considered chronic cholecystitis.

17. Classification Chronic cholecystitis is divide into:
1) chronic calculous
2) chronic non-calculous.

18. Chronic calculous cholecystitis

19. Division of chronic cholecystitis
primary;
recurrent;
complicated.

20. Diagnosis program 1. Anamnesis and physical examination.
2. Survey sciagraphy of organs of abdominal cavity.
3. Peroral and intravenous cholegraphy.
4. Sonography.
5. General analysis of blood and urine.

21. Diagnosis program 6. Analysis of urine on diastasis.
7. Biochemical blood test (bilirubin, amylase, hepatic tests).
8. Coagulogram.
9. Duodenal intubation.
10. Endoscopy.

22. Conservative treatment
Conservative treatment must be basic at for patients with non-calculous chronic cholecystitis It includes:
— table № 5 by Peusner;
— choleic preparations (alohol, holagol, holenzyme, holosas, olimetyn);

23. Conservative treatment
— cholekinetics (sulfate of magnesium, cholecystokinin, pituitrin);
— spasmolytics (sulfate of atropine, platyphyllin, methacin, aminophylline);
— duodenal intubation;
— antibacterial preparations (during acuteening).

24. Obturative icterus
A obturative icterus is the type of icterus the reason of which is violation of patency of bilious ways as a result of their obstruction from within or external compression, or cicatrix narrowing.

25. Classification (by О.О. Shalimov, 1993)
Obturation icteruses are divided into:
I. According to the level of barrier:
1) obstruction of distal parts of general bilious duct;
2) obstruction of supraduodenal part of general bilious duct;
3) obstruction of initial part of general hepatic duct and fork of hepatic ducts.

26. Classification II. According to the etiologic factor:
1) conditioned by obturation by bilious concrement, strange bodies, grume of blood during hemobilia, parasite, iatrogenic influence during operation;
2) obstruction at the diseases of wall of bilious ways — innate anomalies (hypoplasia, cysts and atresia), inflammatory diseases (obstructing papillitis and cholangitis), scar strictures (posttraumatic and inflammatory), bilious ways tumours of high quality;

27. Classification
3) obstruction caused by the out-of- ducts diseases, that pull them in the process (tubular stenosis of general bilious duct of pancreatic genesis, ulcerous disease of duodenum, paracholedocheal lymphadenitis, peritoneal commissures).

28. Classification
. Except that, according to the duration the disease is distinguished:
1) acute obturative icterus, that to 10 days last;
2) protracted, that proceeds from 10 to 30 days;
3) chronic, that more than a month lasts.

29. An icterus of sclera.

30. Diagnosis program 1. Anamnesis and physical methods of examination.
2. General analysis of blood and urine.
3. Analysis of urine on diastasis.
4. Biochemical blood test (bilirubin, urea, albumin-globulin coefficient, blood on an australian antigen, amylase, alanine aminotransferase, asparaginase, alkaline phosphatase).
5. Coagulogram.

31. Diagnosis program 6. Sonography. 7. Endoscopy.
8. Retrograde cholangiopancreatography.
9. Laparoscopy with biopsy.
10. Percutaneous transhepatic cholangioduodenography.
11. Computer tomography.

32. Cirrhosis of liver, intrahepatic portal hypertension
The cirrhosis of liver is a chronic progressive disease, the characteristic signs of which are the defeats of parenchymatous and interstitial tissue of organ, necrosis and dystrophy of hepatic cells, with the subsequent node regeneration as diffuse excrescence of connecting tissue.

33. Classification
According to Havana classification (1956), cirrhosises are divided into:
1) portal; 2) bilious; 3) postnecrosis; ) mixed.
According to the stages of development:
1) initial; 2) formed cirrhosis; 3) dystrophic.

34. Classification According to the degree of weight:
1) easy; 2) middle; 3) heavy.
According to passing:
1) progressive; 2) stable; 3) regressing

35. Diagnosis program 1. Anamnesis and physical examination.
2. General analysis of blood and urine.
3. Biochemical blood test (albuminous factions, bilirubin, glucose, AlAT, ASAT, alkaline phosphatase, cholesterol, reaction of Takata-ara, the Veltmann test; electrophoresis albumens).
4. Coagulogram.

36. Diagnosis program 5. Endoscopy.
6. Contrasting sciagraphy of oesophagus, stomach.
7. Sonography.
8. Scanning of livers.
9. Splenoportography.
10. Laparoscopy.

37. Surgical treatment Operative treatments are divided into two groups:
1) radical, that can liquidate portal stagnation;
2) palliative, which are able only to level the separate signs of this pathology.