Diagnosis of hepatitis, Diagnosis of hepatitis, cholecystitis, liver cholecystitis, liver cirrhosis.cirrhosis.

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

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.

Clinical manifestations of hepatitis and cirrhosis of the liver: Asthenic syndrome. Asthenic phenomena accompany most liver diseases are often the first signs of illness. Characterized by weakness, decreased performance, increased fatigue, loss of previous interests reduction initiatives. Changing emotional background of the man - depressed mood, depression,

irritability episodes

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.

Abdominal pain. Abdominal pain. The most easy option - a feeling of heaviness, pressure in the upper abdomen. Monotone pain in the right upper quadrant due to stretching of the fibrous membrane of the liver, most often appear after eating. Pain can be long or sharp. Sometimes the pain is located in the right subcostal area , and under the breasts.

Cholestatic syndrome.Cholestatic syndrome. Manifested persistent or intermittent Manifested persistent or intermittent ochrodermia, skin itching, dark urine, ochrodermia, skin itching, dark urine, feces feces lighteninglightening. .

Vehetodystonic syndrome.Vehetodystonic syndrome.Psycho-emotional instability, insomnia, Psycho-emotional instability, insomnia, headache, cardialgia, fluctuations inheadache, cardialgia, fluctuations in

blood pressure, sweatingblood pressure, sweating..

Febrile syndrome.Febrile syndrome.

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

Articular syndrome.Articular syndrome.

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

Hemorrhagic syndrome.Hemorrhagic syndrome.

Bleeding from the nose and gums, subcutaneous hemorrhage, menorrhagia, bloody vomiting, tarric excrements. Edematous-ascitic syndrome. Fluid retention, increasing the size of the abdomen, swelling of the legs. Entsefalopatyc syndrome.Memory loss, drowsiness, dyzoriyentation in time and space, inappropriate behavior.

ClassificationClassification

I.I. Etiology:Etiology:viralviralalcoholicalcoholicaautoimmuneutoimmunetoxictoxicddrug (toxic-allergic)rug (toxic-allergic)nnonspecific reactiveonspecific reactive

Secondary biliary Secondary biliary hepatitis with hepatitis with hepatic cholestasis hepatic cholestasis outsideoutside

II. II. The morphological changes:1. Persyst1. Persysticic2. 2. LLobularobular3. Activities:3. Activities:a) with moderate a) with moderate activity;activity;  b) a high degree of   b) a high degree of activity.activity.4. 4. CCholestaticholestatic

ClassificationClassification

III. The clinical course:III. The clinical course:

Phase Phase of of aggravationaggravation

Phase Phase of of remissionremission

IV. For the functional IV. For the functional state of the liver:state of the liver:

compensatedcompensated

ddecompensatedecompensated

Physical examination:Physical examination:

--Skin - grSkin - greeyish-pale, can be local or diffuse yish-pale, can be local or diffuse hyperpigmentation (melasma). hyperpigmentation (melasma). -Jaundice - develops when hyperbilirubinemia above 30 -Jaundice - develops when hyperbilirubinemia above 30 mmol / l, expressed in bilirubin more than 120 mmol / l. mmol / l, expressed in bilirubin more than 120 mmol / l.

-Originally jaundice appears on the palate and sclera, -Originally jaundice appears on the palate and sclera, sometimes there is only partial ochrodermia nasolabial sometimes there is only partial ochrodermia nasolabial triangle, forehead, palms. Itching and traces triangle, forehead, palms. Itching and traces solutions,solutions, caused an increase in the skin of bile acids.caused an increase in the skin of bile acids.--TelTeleeangiectasia, or star-shaped angiomas on the neck, angiectasia, or star-shaped angiomas on the neck, face, shoulders, back , racemes. Their expression is face, shoulders, back , racemes. Their expression is reduced in the fall of blood pressure, bleeding. reduced in the fall of blood pressure, bleeding. Xanthoma - internally yellow skin plaques that form in Xanthoma - internally yellow skin plaques that form in severe hyperlipidemia.severe hyperlipidemia.

Hemorrhage into the skinHemorrhage into the skin - - pinpoint pinpoint hemorrhages develop in protracted course of hemorrhages develop in protracted course of hepatitis.hepatitis. For chronic liver disease characterized by For chronic liver disease characterized by painless superficial hemorrhages in the skin painless superficial hemorrhages in the skin and mucous membranes, bleeding from the and mucous membranes, bleeding from the gums, nose, uterine bleeding.gums, nose, uterine bleeding. Palmar eritema (liver palms) - symmetric Palmar eritema (liver palms) - symmetric splotchy red palms and soles. Spots splotchy red palms and soles. Spots become become palepale with pressing with pressing and again blush at the and again blush at the termination of pressure.termination of pressure. "Crimson, the cardinal's tongue" - and no "Crimson, the cardinal's tongue" - and no sinergy ofsinergy of papillae of the tongue to the papillae of the tongue to the degree of "patent" surface. Atrophy of the degree of "patent" surface. Atrophy of the shoulder musculature due to violation of shoulder musculature due to violation of protein metabolismand hormonal imbalance.protein metabolismand hormonal imbalance.

There is thickening of the distal There is thickening of the distal phalanges of the fingers of the type phalanges of the fingers of the type "drumsticks“"drumsticks“

Gynecomastia Gynecomastia - - female type hair on the female type hair on the body develops as a result of increased body develops as a result of increased estrogen levels. estrogen levels. Possible loss of pubic hair, axillary Possible loss of pubic hair, axillary areas, testicular atrophy. Syndrome areas, testicular atrophy. Syndrome most often occurs in alcoholic hepatitis. most often occurs in alcoholic hepatitis.

Leg swelling, lymphadenopathy - Leg swelling, lymphadenopathy - arisesarises in severe hypoalbuminemia.in severe hypoalbuminemia.

Enlargement of the liver - a Enlargement of the liver - a characteristic sign of its parenchyma. characteristic sign of its parenchyma.

Reducing the size of the liver is rare, in Reducing the size of the liver is rare, in the later stages of cirrhosis of the liver the later stages of cirrhosis of the liver is a bad prognostic sign. On palpation is a bad prognostic sign. On palpation the liver during severe pathological the liver during severe pathological process activity observed liver process activity observed liver tenderness. Liver tissue is sealed, the tenderness. Liver tissue is sealed, the edge can be condensed, the pointed, edge can be condensed, the pointed, hilly. hilly.

Splenomegaly is not typical for most Splenomegaly is not typical for most cases of hepatitiscases of hepatitis

Diagnostic tests. Diagnostic tests. -Zag en. blood - anemia, leykopeniya. -Zag en. blood - anemia, leykopeniya. Acute Acute alcoholic alcoholic hepatitis occurs with leukocytosis, a sharp increase in hepatitis occurs with leukocytosis, a sharp increase in ESR, stab shift.ESR, stab shift. - -Tjtal Tjtal urineurine test test - a possible micro hematuria, mild - a possible micro hematuria, mild proteinuriaproteinuria-biochem. of blood - an increase of ALT and AST, -biochem. of blood - an increase of ALT and AST, hlutamathlutamat dehidrohenazdehidrohenazee, lactate dehydrogenase, iron, , lactate dehydrogenase, iron, vitamin B12, an alkaline phosphatase linked (direct) vitamin B12, an alkaline phosphatase linked (direct) bilirubin, total bilirubin, cholesterolbilirubin, total bilirubin, cholesterol,, reduced albumin, reduced albumin, protein, prothrombin complex.protein, prothrombin complex.-Sonography -Sonography of of liver: increaseliver: increasedd in size, increased in size, increased density heterogeneity density heterogeneity of of ehostrukturehostruktureses. . -Radionuclide study -Radionuclide study of of liver. Used radiopharmaceutical liver. Used radiopharmaceutical Bengal pink for study of liver function.Bengal pink for study of liver function.- Morphological study of the liver - punctures on - Morphological study of the liver - punctures on biopsy.biopsy.

Treatment Treatment depends on the etiology, process activity severity. depends on the etiology, process activity severity. A during acute process. A during acute process. Bedrest Bedrest Diet 5 Diet 5 Drugs that improve metabolism in liver cells - ATP, Vit. Drugs that improve metabolism in liver cells - ATP, Vit. BB group group, , GGlutamiclutamic acid acid.. Hepatoprotectors: Essenciale forte, Gepabene, Sealy Hepatoprotectors: Essenciale forte, Gepabene, Sealy boron, boron, VVitohepatitohepat.. Glucocorticoids: Glucocorticoids: PPrednisolone, rednisolone, MMethyl ethyl PPrednisolone (at rednisolone (at high process activity).high process activity). Amino quinoline drugs: Amino quinoline drugs: DDelahil, elahil, PPlakvenil, lakvenil, immunosuppressive drugs: immunosuppressive drugs: AAzathioprine, zathioprine, CCyclosporine. yclosporine. when viral hepatitis B, C, D - interferons α, β, γ. when viral hepatitis B, C, D - interferons α, β, γ. Detoxification Therapy - Detoxification Therapy - GGemodez, emodez, GGlucose, lucose, SSodium odium TThiosulfatehiosulfate,, enzyme preparations. enzyme preparations. Adsorbents bile acids - Adsorbents bile acids - BBilihnin, ilihnin, CCholestyramine, holestyramine, AActivated carbon with vitamins A, D, E, K, ctivated carbon with vitamins A, D, E, K, EEnterodez, nterodez, UUrsofalk.rsofalk. Oxygen therapy, herbal medicine Bile - Oxygen therapy, herbal medicine Bile - YYarrow, arrow, IImmortelle, mmortelle, HHypericum, ypericum, RRose, ose, DDandelion roots.andelion roots.

Cirrhosis Cirrhosis This is a progressive, diffuse, This is a progressive, diffuse, ppolyetiological olyetiological disease characterized by a significant disease characterized by a significant decrease in the mass of functioning decrease in the mass of functioning hepatocytes, fibrosis with impaired hepatic hepatocytes, fibrosis with impaired hepatic lobule structure and vasculature liver.lobule structure and vasculature liver.

EtiologyEtiology

1.1. AlcoholicAlcoholic2.2. Virus (HBV, HVC, HBV + HDV)Virus (HBV, HVC, HBV + HDV)3.3. Primary biliary cirrhosisPrimary biliary cirrhosis4.4. Secondary biliary cirrhosisSecondary biliary cirrhosis5.5. Violation of venous outflow from the liverViolation of venous outflow from the liver6.6. MetabolicMetabolic7.7. ToxicToxic8.8. NutritionalNutritional9.9. CryptogenicCryptogenic10.10. Parasitic diseasesParasitic diseases11.11. Shunt surgery for intestinalShunt surgery for intestinal

Diagnosis.Diagnosis. Main Main symptoms and symptoms and syndromes:syndromes: Astenovegetative, edematous syndrome, Astenovegetative, edematous syndrome,

endotoxemia, hyperbilirubinemia, diarrhea, endotoxemia, hyperbilirubinemia, diarrhea, intrahepatic cholestasis, portokavalnoho bypass, intrahepatic cholestasis, portokavalnoho bypass, hepatomegaly, splenomegaly, mesenchymal-hepatomegaly, splenomegaly, mesenchymal-inflammatory, cytolytic, bleeding, hepatocellular inflammatory, cytolytic, bleeding, hepatocellular failure, portal hypertension, malabsorption, failure, portal hypertension, malabsorption, anemia, hormonal imbalance.anemia, hormonal imbalance.

Physical dataPhysical data

Resized and seal liverResized and seal liver Palpable spleen determinedPalpable spleen determined Spider veins on the upper trunk and Spider veins on the upper trunk and

faceface Palmar erythemaPalmar erythema Gynecomastia and testicular atrophyGynecomastia and testicular atrophy Veins on the anterior abdominal wallVeins on the anterior abdominal wall AscitesAscites jaundicejaundice

Laboratory parametersLaboratory parameters

Hematologic: concentration of Hb, # of Hematologic: concentration of Hb, # of leukocytes and platelets, Coagulation, blood leukocytes and platelets, Coagulation, blood type, Rh factor, prothrombin index.type, Rh factor, prothrombin index.

Biochemical: bilirubin, albumin, globulin, Biochemical: bilirubin, albumin, globulin, chloride, urea, creatinine, K, Na, copper, iron, chloride, urea, creatinine, K, Na, copper, iron, Ig in the serum activity of ALT, AST, alkaline Ig in the serum activity of ALT, AST, alkaline phosphatase.phosphatase.

Immunological indices serumImmunological indices serumHBsAg, anti-HVC, antibodies to smooth HBsAg, anti-HVC, antibodies to smooth muscle, to soluble liver antigen, α-feto-protein.muscle, to soluble liver antigen, α-feto-protein.

Instrumental researchInstrumental research

EsophagogastroduodenoscopyEsophagogastroduodenoscopy Doppler-ultrasound liverDoppler-ultrasound liver Computed tomography of the liverComputed tomography of the liver Krizshkirna needle biopsyKrizshkirna needle biopsy Radioisotope scanning of the liverRadioisotope scanning of the liver Fluoroscopy esophagus and stomachFluoroscopy esophagus and stomach

Treatment of cirrhosisTreatment of cirrhosis

Regieme - depending on the stage of Regieme - depending on the stage of cirrhosis.cirrhosis.

Diet № 5 in portal hypertension - bezso Levu, Diet № 5 in portal hypertension - bezso Levu, in hepatic coma - in hepatic coma - PProtein-free.rotein-free.

Detoxification therapy: Neogemodez, Detoxification therapy: Neogemodez, GGlucose.lucose.

Anti-inflammatory therapy: steroids, Anti-inflammatory therapy: steroids, antibiotics, immunosuppressants, antibiotics, immunosuppressants, hepatoprotectors, adsorbents bile acids, hepatoprotectors, adsorbents bile acids, drugs that improve metabolism in drugs that improve metabolism in hepatocytes, pancreatic enzymeshepatocytes, pancreatic enzymes

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

Chronic non-calculous (Chronic non-calculous (bilestone freebilestone free) ) cholecystitis (sholecystitis chronica) - a chronic cholecystitis (sholecystitis chronica) - a chronic inflammatory diseaseinflammatory disease..

Polyetiological gall bladder, which is Polyetiological gall bladder, which is combined with motor-tonic disorders combined with motor-tonic disorders (dyskinesia), biliary tract and changes in (dyskinesia), biliary tract and changes in physico-chemical properties and biochemical physico-chemical properties and biochemical composition of bile (dysholicomposition of bile (dysholiaa).).

Etiology.Etiology.

1.1. Bacterial infectionsBacterial infections

2.2. Parasitic infestationParasitic infestation

3.3. Duodenobiliar refluxDuodenobiliar reflux

4.4. AllergiesAllergies

5.5. Chronic inflammatory disease of the Chronic inflammatory disease of the digestive system.digestive system.

6.6. Acute cholecystitis.Acute cholecystitis.

Predisposing factorsPredisposing factors

1.1.Stagnation of bile.Stagnation of bile.2.2.Reflex effects from abdominal organs during Reflex effects from abdominal organs during development in their overall process.development in their overall process.3.3.Intestinal dysbiosis.Intestinal dysbiosis.4.4.Metabolic disorders contributing to changes Metabolic disorders contributing to changes in physico-chemical properties and in physico-chemical properties and composition of bile (obesity, diabetes, gout).composition of bile (obesity, diabetes, gout).5.5.Hereditary with respect to XX.Hereditary with respect to XX.

The main pathogenic The main pathogenic factors:factors:

1.1. Neurodegenerative changes ZHM wall.Neurodegenerative changes ZHM wall.

2.2. Neuroendocrine disorders.Neuroendocrine disorders.

3.3. Stagnation and dysholiya bile.Stagnation and dysholiya bile.

4.4. Violation of the wall ZHM.Violation of the wall ZHM.

5.5. Factors:Factors:Allergic reactions and Allergic reactions and Immunoinflammatory.Immunoinflammatory.

Classification of chronic Classification of chronic cholecystitischolecystitis

1.1. Etiology: kolibatEtiology: kolibatciliccilic, enterokok, enterokokcialcial, strepto-, stafilo-, , strepto-, stafilo-, pneumococcal, Salmonella, typhoid, dysentery, pneumococcal, Salmonella, typhoid, dysentery, brutselozbrutselozal, al, paratyphoid and others.paratyphoid and others.

2.2. The degree of severity: mild, moderate, severe.The degree of severity: mild, moderate, severe.3.3. The nature of the course: recurring, monotonous, The nature of the course: recurring, monotonous,

intermittent.intermittent.4.4. During phases: pointed, During phases: pointed, decreasingdecreasing exacerbation exacerbation,,

stable remission, unstable remission.stable remission, unstable remission.In the presence of complications, uncomplicated, In the presence of complications, uncomplicated, complicated percomplicated periiholeholeciciststiittisis..

ClinicalClinical

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

Physical examinationPhysical examination ..Review. Review. Most patients say overweight.Most patients say overweight.

In some patients there subiIn some patients there subicctertericity oficity of sclera sclerass and skin. and skin.Palpation marked tenderness in the region of the gallbladder.Palpation marked tenderness in the region of the gallbladder.May show some positive signs:May show some positive signs:Symptom Zakharyin - pain when pressing the point ZHM.Symptom Zakharyin - pain when pressing the point ZHM.S-mS-m of of Vasilenko - when tapped at the point ZHM at the height Vasilenko - when tapped at the point ZHM at the height of inspiration there is a sharp pain.of inspiration there is a sharp pain.S-m of S-m of ObraztsovObraztsov--Murphy - after clicking on the area offered Murphy - after clicking on the area offered ZHM patient to breathe, while the patient "intercepts" breath of ZHM patient to breathe, while the patient "intercepts" breath of pain in the ZHM.pain in the ZHM.SS-m -m of of Ker - pain on vdosi during palpation right Ker - pain on vdosi during palpation right hypochondrium.hypochondrium.SS-m -m of of Ortner - pain when tapped his hand on the edge of right Ortner - pain when tapped his hand on the edge of right costal arch.costal arch.SS-m-m of of Myusi cardiology - pain at the point of the phrenic nerve Myusi cardiology - pain at the point of the phrenic nerve (frenikus-symptom).(frenikus-symptom).

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

Laboratory and instrumental methodsLaboratory and instrumental methods 1. Total blood: moderate leukocytosis, left shift with increasing stab leukocytes,

ESR acceleration.2. Biochemical analysis of blood: an exacerbation of increased content of

sialic acids seromucoid, fibrin, alpha 2-globulin, possibly gamma globulin.3. Imunolohiche blood research: reduced number of B and T lymphocytes

and IgA.4. 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.

5. ultrasound:5. ultrasound:

Echo signs of Mts. cholecystitisEcho signs of Mts. cholecystitisZHM wall thickening greater than 2 mm;ZHM wall thickening greater than 2 mm;sealing wall, especially with thickening;sealing wall, especially with thickening;unevenness and deformation path bladder, unevenness and deformation path bladder, increase or decrease the size, adhesions;increase or decrease the size, adhesions;reduction or absence of motion ZHM reduction or absence of motion ZHM breathing;breathing;nnononhomohomoggenenouseouse content content of of "gall "gall precipitate."precipitate."

Ultrasound of the liver and gall bladder

6. Ro-study ZHM:6. Ro-study ZHM:Cholecystography:Cholecystography:Signs HNHSigns HNH  - Impaired concentration ability and motor function   - Impaired concentration ability and motor function ZHM (sharp slowdown emptying ZHM);ZHM (sharp slowdown emptying ZHM);  - ZHM deformity (inequality contours due   - ZHM deformity (inequality contours due pereholepereholeccystystiittisis).).

7. Computed tomography ZHM.7. Computed tomography ZHM.

8. Radioisotope studies of biliary tract:8. Radioisotope studies of biliary tract:Symptoms: - persistent infringement speed filling Symptoms: - persistent infringement speed filling and emptying ZHM;and emptying ZHM;increase or decrease its size;increase or decrease its size;seal lying ZHM.seal lying ZHM.

9. Thermography: observed local temperature increase 9. Thermography: observed local temperature increase of 0,3 -2 ° C, zone ZHM looks bright.of 0,3 -2 ° C, zone ZHM looks bright.

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

TreatmentTreatment1.1. In acute patient lax recommend bed rest for 7-10 days, 1-2 In acute patient lax recommend bed rest for 7-10 days, 1-2

days a warm drink.days a warm drink.2.2. Diet № 5, frequent meals (5-6 times / day)) in small portions.Diet № 5, frequent meals (5-6 times / day)) in small portions.3.3. Purchasing painPurchasing pain

m anticholinergics: m anticholinergics: AAtropine tropine SSulfate, ulfate, MMethacin, ethacin, PPlatifillin latifillin GGidrotartrata, idrotartrata, GGastrotsepin;astrotsepin;antispasmodics: antispasmodics: PPapaverine, Nospanum;apaverine, Nospanum;AAnalgesics: nalgesics: PProteins, roteins, BBaralgin, aralgin, DDroperiodol.roperiodol.

4.4. Antibiotic therapy in acute.Antibiotic therapy in acute.5.5. Appointed when thinking about the nature of the bacterial Appointed when thinking about the nature of the bacterial

disease have clinical and laboratory data confirming the disease have clinical and laboratory data confirming the activity of the inflammatory process in ZHM (activity of the inflammatory process in ZHM (EErythromycin, rythromycin, AAmpicillin, mpicillin, OOxacillin, xacillin, LLincomycin, incomycin, FFurazolizon, urazolizon, PPenicillin, enicillin, TTetracycline, etracycline, BBlacks, lacks, TTaryvid, aryvid, CCephalosporin antibiotics).ephalosporin antibiotics).

6.6. Detoxification therapy in very severe exacerbation of Detoxification therapy in very severe exacerbation of symptoms of intoxication: broths hips, alkaline mineral water / symptoms of intoxication: broths hips, alkaline mineral water / drip - gemodez, polidez, 5% glucose isotonic district.drip - gemodez, polidez, 5% glucose isotonic district.

7. Bile means.7. Bile means. Rational choice bile depends on the phase of chronic Rational choice bile depends on the phase of chronic

cholecystitis and concomitant type dyskinesia.cholecystitis and concomitant type dyskinesia. 1) drugs that stimulate the formation of liver bile - Bile 1) drugs that stimulate the formation of liver bile - Bile

true (choleretic):true (choleretic): preparations containing bile acids (Hologon, Deholin, preparations containing bile acids (Hologon, Deholin,

Alahol, Festal, Holenzim, Liobil);Alahol, Festal, Holenzim, Liobil); synthetic choleretic (Nikodin, Tsykvalon, Oksafenamid);synthetic choleretic (Nikodin, Tsykvalon, Oksafenamid); vegetable (Immortelle, Corn Silk, Flamini, Peppermint, vegetable (Immortelle, Corn Silk, Flamini, Peppermint,

Holosas, Parsley);Holosas, Parsley); hidroholiretyky (water type "NAFTA");hidroholiretyky (water type "NAFTA"); 2) drugs that stimulate bile (holekinetiki): Xylitol, 2) drugs that stimulate bile (holekinetiki): Xylitol,

Sorbitol, MgSO4, Tansy.Sorbitol, MgSO4, Tansy.

8.8. Normalization function of the autonomic NS: Normalization function of the autonomic NS: sedativ, minor tranquilizers.sedativ, minor tranquilizers.

9.9. Immunomodulatory therapy: Timalin, T-Immunomodulatory therapy: Timalin, T-aktyvhin, Sodium Nukleinat, Adaptogens aktyvhin, Sodium Nukleinat, Adaptogens (Ginseng, Pantocrinum, Siberian ginseng).(Ginseng, Pantocrinum, Siberian ginseng).

10.10. Physiotherapy treatment.Physiotherapy treatment.11.11. When stihanii acute phenomena - When stihanii acute phenomena -

inductothermy, UHF, microwave, SMT, UST, inductothermy, UHF, microwave, SMT, UST, electrophoresis of novocaine, MgSO4, electrophoresis of novocaine, MgSO4, applications paraffin wax, ORT, applications paraffin wax, ORT, balneotherapy.balneotherapy.

12.12. Treatment of mineral water.Treatment of mineral water.13.13. Spa treatment in remission (Truskavets Spa treatment in remission (Truskavets

Gusyatin, Satan, Essentuki, Borjomi).Gusyatin, Satan, Essentuki, Borjomi).

Chronic calculous cholecystitis Chronic calculous cholecystitis (sholecystitis chronica calculosa, cholelithiasis) (sholecystitis chronica calculosa, cholelithiasis) - a disease characterized by the formation of - a disease characterized by the formation of stones in the gallbladder, at least - in the bile stones in the gallbladder, at least - in the bile ducts.ducts.In the development of gallstones are important In the development of gallstones are important metabolic disorders, infection and bile stasis.metabolic disorders, infection and bile stasis.   There are three stages of gallstone disease.   There are three stages of gallstone disease.The first stage (physical and chemical).The first stage (physical and chemical).The second stage (latent) is characterized by The second stage (latent) is characterized by changes in lithogenic bile to form gallstones.changes in lithogenic bile to form gallstones.The third stage of cholelithiasis - clinical The third stage of cholelithiasis - clinical (calculous cholecystitis).(calculous cholecystitis).

ClinicalClinicalSubjective symptoms:Subjective symptoms:

  The most characteristic feature of the disease is a   The most characteristic feature of the disease is a liver or biliary colic. Intense pain localized in the right liver or biliary colic. Intense pain localized in the right upper quadrant and epigastric, radiating to the back, upper quadrant and epigastric, radiating to the back, chest thing, right shoulder, shoulder, arm. Join chest thing, right shoulder, shoulder, arm. Join nausea, repeated vomiting, which does not facilitate nausea, repeated vomiting, which does not facilitate pain, bloating, delayed stool. With prolonged fit of pain, bloating, delayed stool. With prolonged fit of itching appears.itching appears.

Physical examination.Physical examination.On examination can detect jaundice (the second day), On examination can detect jaundice (the second day), xanthoma. There bloating, muscle tension and local xanthoma. There bloating, muscle tension and local tenderness in the right upper quadrant. Positive gall-tenderness in the right upper quadrant. Positive gall-mihurni symptoms and areas of hyperesthesia (lower mihurni symptoms and areas of hyperesthesia (lower angle shoulder, shoulder area, paravertebral right from angle shoulder, shoulder area, paravertebral right from VIII to IX thoracic vertebra).VIII to IX thoracic vertebra).

Xanthelasma of the upper eyelid

Laboratory and instrumental methodsLaboratory and instrumental methodsIn the biochemical analysis of blood observed increase in In the biochemical analysis of blood observed increase in cholesterol levels, increasing the activity of alkaline cholesterol levels, increasing the activity of alkaline phosphatase.phosphatase.Ultrasound. The smallest size of stones that can diagnose = 1-2 Ultrasound. The smallest size of stones that can diagnose = 1-2 mm. Often unable to determine sediment (sand) in ZHM.mm. Often unable to determine sediment (sand) in ZHM.Cholecystography. Stones in the bile ducts and ZHM seen as a Cholecystography. Stones in the bile ducts and ZHM seen as a zone of enlightenment.zone of enlightenment.

Treatment.Treatment.First stage: diet number 5, eat lots of vegetables, fruits, First stage: diet number 5, eat lots of vegetables, fruits, regularly engage in physical activity, obesity be prevented.regularly engage in physical activity, obesity be prevented.Second stage: to dissolve cholesterol (Second stage: to dissolve cholesterol (x-RAY negativex-RAY negative) ) gallstones prescribe (gallstones prescribe (HHenohol, enohol, HHenofalk) and enofalk) and urodyzoksyholevoyi (urodyzoksyholevoyi (UUrsofalk, Urso - 100) acids.rsofalk, Urso - 100) acids.In the third stage of the disease, during an attack of bilious In the third stage of the disease, during an attack of bilious colic, the patient admitted to the surgical department. Assign colic, the patient admitted to the surgical department. Assign antispasmodics, analgesics, if necessary - to operate.antispasmodics, analgesics, if necessary - to operate.

Cholangitis (angiocholitis - cholaengitis)Cholangitis (angiocholitis - cholaengitis) - - inflammation of the bile ducts. There are acute and chronic inflammation of the bile ducts. There are acute and chronic cholangitis. Chronic cholangitis may be latent, recurrent cholangitis. Chronic cholangitis may be latent, recurrent and prolonged septic component of the course.and prolonged septic component of the course.

ClinicalClinicalThe feeling of heaviness or dull pain in the right upper The feeling of heaviness or dull pain in the right upper quadrant, which occurs in violation diet bumpy ride, quadrant, which occurs in violation diet bumpy ride, physical work. The pain spread to the right shoulder and physical work. The pain spread to the right shoulder and shoulder.shoulder.  Diarrheal syndrome: a bitter taste in the mouth, aversion   Diarrheal syndrome: a bitter taste in the mouth, aversion to fatty foods, nausea when inhaled the smell of this dish.to fatty foods, nausea when inhaled the smell of this dish.Itching of the skin that can occur to limit the area.Itching of the skin that can occur to limit the area.Astenodepresyvnyy syndrome: weakness.Astenodepresyvnyy syndrome: weakness.Long periods of unwarranted subfebrile with periodic Long periods of unwarranted subfebrile with periodic fever. When viewed subikteryc mucous. They exhibit a fever. When viewed subikteryc mucous. They exhibit a larger soft, tender liver.larger soft, tender liver.

Laboratory and instrumental Laboratory and instrumental

methodsmethods Complete blood count: leukocytosis, left shift, accelerated Complete blood count: leukocytosis, left shift, accelerated

ESR, anemia.ESR, anemia. Biochemical analysis of blood: increased bilirubin, alpha 2 and Biochemical analysis of blood: increased bilirubin, alpha 2 and γ-globulin, transaminases, alkaline phosphatase, γ-γ-globulin, transaminases, alkaline phosphatase, γ-hlyutamiltranspeptydazy, sialic acid, fibrin.hlyutamiltranspeptydazy, sialic acid, fibrin. Urine lab. the possible emergence of protein cylinders bilirubin. Urine lab. the possible emergence of protein cylinders bilirubin. Fractional duodenal intubation. Portion B - a large number of Fractional duodenal intubation. Portion B - a large number of shallow cylindrical epithelium. Portion C - bacterial flora, shallow cylindrical epithelium. Portion C - bacterial flora, leukocytes, increase in sialic acid, fibrin, enzymes.leukocytes, increase in sialic acid, fibrin, enzymes. Ultrasound - expanding intrahepatic bile ducts, liver Ultrasound - expanding intrahepatic bile ducts, liver enlargement.enlargement. Intra / a cholangiography or endoscopic retrograde pankreato Intra / a cholangiography or endoscopic retrograde pankreato--holanholanggiohraiohraphphy exhibit advanced bile duct.y exhibit advanced bile duct.

TreatmentTreatment

Diet number 5a;Diet number 5a;antibacterial;antibacterial;bbile med-s.ile med-s.iif necessaryf necessary - - surgery. surgery.

HepatorenalHepatorenal syndrome. About hepatorenal syndrome talking syndrome. About hepatorenal syndrome talking when along with marked and anatomicwhen along with marked and anatomically provenally proven liver and liver and biliary tract revealed signs of kidney damage. It is most biliary tract revealed signs of kidney damage. It is most commonly observed in liver cirrhosis.commonly observed in liver cirrhosis.

Cholestatic syndrome. (Cholestasis syndrome). It is Cholestatic syndrome. (Cholestasis syndrome). It is characterized by dark, like brown skin, intense itching, which characterized by dark, like brown skin, intense itching, which precedes the appearance of jaundice. On the palms in the precedes the appearance of jaundice. On the palms in the corners of the eyes, the outer surface of the elbows, knees flat corners of the eyes, the outer surface of the elbows, knees flat formation appear yellow due to hypercholesterolemia - formation appear yellow due to hypercholesterolemia - xanthelasma. In some cases there may be fever, chills. In blood xanthelasma. In some cases there may be fever, chills. In blood levels of conjugated bilirubin, cholesterol, β-lipoprotein, levels of conjugated bilirubin, cholesterol, β-lipoprotein, hemahlyutamintransferazy. Urine is dark in color, like color of hemahlyutamintransferazy. Urine is dark in color, like color of beer, feces may be bright.beer, feces may be bright.

The syndrome of hepatic failure (insuffitientia hepatitis) - is a The syndrome of hepatic failure (insuffitientia hepatitis) - is a violation of the liver, accompanied by severe disorders of violation of the liver, accompanied by severe disorders of homeostasis and violation of the internal organs, especially the homeostasis and violation of the internal organs, especially the central nervous system.central nervous system.

Diarrheal syndrome is characterized by nausea, spitting, Diarrheal syndrome is characterized by nausea, spitting, heartburn, vomiting, appetite disturbance.heartburn, vomiting, appetite disturbance.

Pain in the right upper quadrant.Pain in the right upper quadrant.

Chronic autoimmune hepatitisChronic autoimmune hepatitis More common in girls and young women aged 10-30 years, at More common in girls and young women aged 10-30 years, at

least women in menopause. According to the literature, the least women in menopause. According to the literature, the ratio of women and men in this disease 3-1.ratio of women and men in this disease 3-1.

Beginning disease can manifest weakness, anorexia, dark Beginning disease can manifest weakness, anorexia, dark urine, jaundice prior. Chance of a extrahepatic manifestations: urine, jaundice prior. Chance of a extrahepatic manifestations: fever, joint damage that gives rise to the diagnosis of rheumatic fever, joint damage that gives rise to the diagnosis of rheumatic fever, fever, lupuslupus. .

In later stages: fever to subfebrile digits combined with In later stages: fever to subfebrile digits combined with arthralgia. The process involved large joints of the upper and arthralgia. The process involved large joints of the upper and lower extremities, occasionally spine.lower extremities, occasionally spine.

Configuration joints varies mainly due peryartykulyar Configuration joints varies mainly due peryartykulyar inflammation and tendon-muscle syndrome.inflammation and tendon-muscle syndrome.

Chronic autoimmune hepatitis is a systemic disease with Chronic autoimmune hepatitis is a systemic disease with lesions of the skin, mucous membranes and internal organs. It lesions of the skin, mucous membranes and internal organs. It is characterized by the presence of pleuritis, myocarditis, is characterized by the presence of pleuritis, myocarditis, pericarditis, ulcerative colitis, glomerulonephritis. pericarditis, ulcerative colitis, glomerulonephritis.

DescribedDescribed Cushing's syndrome, diabetes, generalized Cushing's syndrome, diabetes, generalized lymphadenopathy, hemolytic anemialymphadenopathy, hemolytic anemia

The disease has a continuous flow. In the study The disease has a continuous flow. In the study revealed an increase in blood levels of bilirubin, revealed an increase in blood levels of bilirubin, aminotransferases. aminotransferases.

Hypergammaglobulinemia occurs so often that one of Hypergammaglobulinemia occurs so often that one of the names of this form of the disease is "progressive the names of this form of the disease is "progressive hhyyperhammaperhammagglobulinemic hepatitis." Typical lobulinemic hepatitis." Typical hypoalbuminemia, significant deviations thymol and a hypoalbuminemia, significant deviations thymol and a sharp slowdown allocation sharp slowdown allocation of of bromsulfaleyin. Possible bromsulfaleyin. Possible signs signs of of hhyypersplenipersplenissmumuss (platelets and leukopenia). (platelets and leukopenia). Often there are positive LE-cell phenomenon, Often there are positive LE-cell phenomenon, antinuclear factor, complement fixation, high (1:160, antinuclear factor, complement fixation, high (1:160, 1:320 and higher) titer of antibodies to tissue smooth 1:320 and higher) titer of antibodies to tissue smooth muscle (the latter is a pathognomonic sign of liver muscle (the latter is a pathognomonic sign of liver damage).damage).

Pain in the right upper quadrant, constantly aching, often Pain in the right upper quadrant, constantly aching, often intense, sharply intensified after exercise. This pain associated intense, sharply intensified after exercise. This pain associated with inflammatory infiltration in the connective tissue in the liver with inflammatory infiltration in the connective tissue in the liver capsule. In some patients the equivalent is the feeling of capsule. In some patients the equivalent is the feeling of heaviness and fullness in the right upper quadrant.heaviness and fullness in the right upper quadrant.

Diarrheal syndrome appears distorted taste of food, constant Diarrheal syndrome appears distorted taste of food, constant nausea, which increases after meals and medication depends nausea, which increases after meals and medication depends on the violation of decontaminating the liver and reactive on the violation of decontaminating the liver and reactive pancreatitis.pancreatitis.

Syndrome "small" liver failure, which manifested drowsiness, Syndrome "small" liver failure, which manifested drowsiness, severe bleeding, transient jaundice and ascites occurs in severe bleeding, transient jaundice and ascites occurs in patients with severe necrotic changes in hepatocytes.patients with severe necrotic changes in hepatocytes.

For cholestasis syndrome characterized by itching, increased For cholestasis syndrome characterized by itching, increased bilirubin, cholesterol, alkaline phosphatase, gamma-bilirubin, cholesterol, alkaline phosphatase, gamma-hlutamiltransferazy serumhlutamiltransferazy serum

Hepatomegaly is found in all cases HVH. In acute liver disease Hepatomegaly is found in all cases HVH. In acute liver disease stands at 5-7 cm from the edge of the arc, it is moderately stands at 5-7 cm from the edge of the arc, it is moderately dense, tapered edge, palpation is painful. Remission dense, tapered edge, palpation is painful. Remission accompanied by a marked decrease in liver. The spleen is accompanied by a marked decrease in liver. The spleen is enlarged slightly.enlarged slightly.

Blood analysis revealed during acute Blood analysis revealed during acute hypergammaglobulinemia, hypoalbuminemia, hypergammaglobulinemia, hypoalbuminemia, increased thymol and activity of aminotransferases increased thymol and activity of aminotransferases (ALT, AST more). Increasing total protein and bilirubin (ALT, AST more). Increasing total protein and bilirubin in serum. In remission, these figures are improving, in serum. In remission, these figures are improving, but do not reach the standards.but do not reach the standards.

Ultrasound shows moderate hepatomegaly with a Ultrasound shows moderate hepatomegaly with a rounded bottom edge of both particles liver. Prolonged rounded bottom edge of both particles liver. Prolonged disease decreases sound conductivity and elasticity of disease decreases sound conductivity and elasticity of the liver. Some diagnostic value has nuclear scans.the liver. Some diagnostic value has nuclear scans.

Chronic hepatitis B (chronic viral hepatitis B) in 10-20% of Chronic hepatitis B (chronic viral hepatitis B) in 10-20% of cases are due to acute process. Major antigenic and serological cases are due to acute process. Major antigenic and serological markers of viral replication - HBV DNA, DNA polymerase, Hbe-markers of viral replication - HBV DNA, DNA polymerase, Hbe-Ag, anti-Ig NBc class M. They are found in patients with chronic Ag, anti-Ig NBc class M. They are found in patients with chronic disease and they are an indicator of activity of the process. The disease and they are an indicator of activity of the process. The presence of NVs-Ag in serum is a sign of viral persistence.presence of NVs-Ag in serum is a sign of viral persistence.

Chronic hepatitis C (HVHS) occupies a special place among Chronic hepatitis C (HVHS) occupies a special place among HVH because 20-50% of cases transformed into cirrhosis. HCV HVH because 20-50% of cases transformed into cirrhosis. HCV virus is heterogeneous, is not less than 6 of its types, which virus is heterogeneous, is not less than 6 of its types, which differ both in the degree of pathogenicity, and the sensitivity to differ both in the degree of pathogenicity, and the sensitivity to interferon. Feature of HCV is that its replication can occur not interferon. Feature of HCV is that its replication can occur not only in the liver tissue, but also in mononuclear cells. This only in the liver tissue, but also in mononuclear cells. This explains poliorhannist damage in HCV. The basis of explains poliorhannist damage in HCV. The basis of extrahepatic manifestations (idiopathic thrombocytopenia, extrahepatic manifestations (idiopathic thrombocytopenia, aplastic anemia, uveitis, lesions of the thyroid gland, systemic aplastic anemia, uveitis, lesions of the thyroid gland, systemic vasculitis, etc.). Lie as a direct effect of the virus, and vasculitis, etc.). Lie as a direct effect of the virus, and autoimmune reactions.autoimmune reactions.

Chronic hepatitis D (XVHD) runs as a mixed infection Chronic hepatitis D (XVHD) runs as a mixed infection because replication of the virus (NDV) is required because replication of the virus (NDV) is required HbsAg hepatitis B virus (HBV).HbsAg hepatitis B virus (HBV).

Chronic drug-induced hepatitis (HMH) - drug liver Chronic drug-induced hepatitis (HMH) - drug liver damage - is an urgent problem due to the increasing damage - is an urgent problem due to the increasing number of different medications, uncontrolled use, number of different medications, uncontrolled use, widespread polypharmacy. HMH is up to 5% of all widespread polypharmacy. HMH is up to 5% of all chronic heptytiv.chronic heptytiv.Damaging factors can be realized in the form of Damaging factors can be realized in the form of autoimmune and toxic reactions. Hepatotoxic agents autoimmune and toxic reactions. Hepatotoxic agents can cause necrosis already in high doses and their can cause necrosis already in high doses and their toxicity increases with dose (chloroform, muscarinic et toxicity increases with dose (chloroform, muscarinic et al.). Effects of other drugs due to idiosyncrasy and is al.). Effects of other drugs due to idiosyncrasy and is independent of dose (chlorpromazine, ftorotan, independent of dose (chlorpromazine, ftorotan, isoniazid, erythromycin, tetracycline, anabolic steroids, isoniazid, erythromycin, tetracycline, anabolic steroids, oral contraceptives, and others.) May manifest oral contraceptives, and others.) May manifest metabolic or immunological disorders.metabolic or immunological disorders.

Chronic cryptogenic (idiopathic) hepatitis. This group includes Chronic cryptogenic (idiopathic) hepatitis. This group includes chronic hepatitis without identified etiology, which may be due chronic hepatitis without identified etiology, which may be due to insufficient sensitivity of existing serological tests, especially to insufficient sensitivity of existing serological tests, especially to certain subtypes faith hepatitis B, C or D, their mutations and to certain subtypes faith hepatitis B, C or D, their mutations and other causes. In addition, it is expected that other types of other causes. In addition, it is expected that other types of hepatitis viruses are not identified so far.hepatitis viruses are not identified so far.

In establishing the diagnosis of chronic hepatitis B should In establishing the diagnosis of chronic hepatitis B should reflect the etiology, pathogenesis, level of activity and stage of reflect the etiology, pathogenesis, level of activity and stage of disease. The degree of activity (weight process) for chronic disease. The degree of activity (weight process) for chronic hepatitis determined by enzyme laboratory tests and hepatitis determined by enzyme laboratory tests and morphological study of liver biopsy. From laboratory signs is to morphological study of liver biopsy. From laboratory signs is to identify the most informative alanine aminotransferase (ALT) - identify the most informative alanine aminotransferase (ALT) - increasing its level of 3-5 reflects the minimum of 5-10 times - increasing its level of 3-5 reflects the minimum of 5-10 times - moderate, more than 10 times - a high degree of activity.moderate, more than 10 times - a high degree of activity.In the morphological study using semi-quantitative analysis of In the morphological study using semi-quantitative analysis of the index of histological activity (ISSAR) - "index Knodel".the index of histological activity (ISSAR) - "index Knodel".

Step hCG reflects prebih disease and is characterized by the Step hCG reflects prebih disease and is characterized by the degree of liver fibrosis until the development of cirrhotic degree of liver fibrosis until the development of cirrhotic changes. There fibrosis: portal, periportal, changes. There fibrosis: portal, periportal, peryhepatotselyulyarnyy.peryhepatotselyulyarnyy.

Weather. In chronic hepatitis mostly favorable, especially after Weather. In chronic hepatitis mostly favorable, especially after the elimination of etiological factors.the elimination of etiological factors.

Prevention of chronic hepatitis includes early diagnosis, Prevention of chronic hepatitis includes early diagnosis, adequate treatment of acute viral hepatitis, clinical supervision adequate treatment of acute viral hepatitis, clinical supervision for him, to prevent exposure to various industrial, medical and for him, to prevent exposure to various industrial, medical and consumer intoxication others.consumer intoxication others.

Treatment of chronic viral hepatitis. Should exclude all Treatment of chronic viral hepatitis. Should exclude all hepatotoxic effects (contact with hepatotropic poisons the hepatotoxic effects (contact with hepatotropic poisons the workplace, alcohol). Obmezhuyetsya heavy physical work. Not workplace, alcohol). Obmezhuyetsya heavy physical work. Not intended medication slowly neutralized liver (tranquilizers, intended medication slowly neutralized liver (tranquilizers, sedatives, analgesics) are contraindicated physiotherapy on the sedatives, analgesics) are contraindicated physiotherapy on the plot liver balneotherapy. In acute disease surgery performed plot liver balneotherapy. In acute disease surgery performed only for health indications.only for health indications.

Recommended diet number 5. Food consumed 4-5 Recommended diet number 5. Food consumed 4-5 times a day in small portions.times a day in small portions.

Drug therapy involves the use of immunostimulants Drug therapy involves the use of immunostimulants (levalizol, timalin, T-activin) and antiviral drugs (levalizol, timalin, T-activin) and antiviral drugs (interferon ademin-arabinoside). The main treatment (interferon ademin-arabinoside). The main treatment for patients with chronic viral hepatitis is interferon for patients with chronic viral hepatitis is interferon (IF). It inhibits virus replication and stimulates the (IF). It inhibits virus replication and stimulates the production of endogenous ineterferonu. Treatments IF production of endogenous ineterferonu. Treatments IF long enough: at least 4-6 months with HVH type B (5-long enough: at least 4-6 months with HVH type B (5-10 million IU 3 times a week subcutaneously or 10 million IU 3 times a week subcutaneously or intramuscularly), up to 18 months at HVH type C (3 intramuscularly), up to 18 months at HVH type C (3 million IU 3 times per week), and 12 months at HVH million IU 3 times per week), and 12 months at HVH type D (10 million IU 3 times a week). Possible type D (10 million IU 3 times a week). Possible combinations of IF with antioxidants dezoksyholevoyu combinations of IF with antioxidants dezoksyholevoyu acid and drugs from the group hepatoprotetoriv acid and drugs from the group hepatoprotetoriv (essentiale, vitamins B, C, etc.).. In chronic (essentiale, vitamins B, C, etc.).. In chronic autoimmune hepatitis commonly used steroids in autoimmune hepatitis commonly used steroids in combination with immunosuppressive drugs.combination with immunosuppressive drugs.

cirrhosiscirrhosis Cirrhosis (sirrhosis hepatis) - Polyetiological chronic Cirrhosis (sirrhosis hepatis) - Polyetiological chronic

progressive disease with severe symptoms in varying progressive disease with severe symptoms in varying degrees of functional liver failure and portal degrees of functional liver failure and portal hypertension, the main feature of which is the hypertension, the main feature of which is the significant growth of connective tissue.significant growth of connective tissue.

The morphological structure distinguish large-, MKD, The morphological structure distinguish large-, MKD, mixed and biliary (primary and secondary) liver.mixed and biliary (primary and secondary) liver.

Mixed (macro-mikronodulyarnu) form is diagnosed Mixed (macro-mikronodulyarnu) form is diagnosed when a number of small and large sites about when a number of small and large sites about equally.equally.

Large-(makronodulyarnyy, postnekrotychnyy) cirrhosis is Large-(makronodulyarnyy, postnekrotychnyy) cirrhosis is characterized by the formation of nodes of various sizes over characterized by the formation of nodes of various sizes over 3mm in diameter. Some units reach 5 cm size liver may be 3mm in diameter. Some units reach 5 cm size liver may be normal, increased and decreased sharply.normal, increased and decreased sharply.

The initial clinical manifestations of large-cirrhosis is often The initial clinical manifestations of large-cirrhosis is often dyspeptic syndrome (loss of appetite, flatulence), asthenia dyspeptic syndrome (loss of appetite, flatulence), asthenia (decreased performance, irritability, hipohondriya), pain or a (decreased performance, irritability, hipohondriya), pain or a feeling of heaviness in the upper abdomen. On examination feeling of heaviness in the upper abdomen. On examination revealed liver enlargement with thickening and deformation of revealed liver enlargement with thickening and deformation of the surface, the liver edge sharpened. Initially, there is a the surface, the liver edge sharpened. Initially, there is a uniform increase in both particle unsharp liver. Subsequently uniform increase in both particle unsharp liver. Subsequently often dominates the increase of the left lobe. Portal often dominates the increase of the left lobe. Portal hypertension in the initial stage shows moderate splenomegaly.hypertension in the initial stage shows moderate splenomegaly.

In the expanded stage of the disease early and persistent In the expanded stage of the disease early and persistent symptoms, regardless of etiological and morphological types is symptoms, regardless of etiological and morphological types is a pain in the right upper quadrant and hepatolienal syndrome. a pain in the right upper quadrant and hepatolienal syndrome. This can be detected signs hipersplenizmu (leukopenia, This can be detected signs hipersplenizmu (leukopenia, thrombocytopenia, anemia).thrombocytopenia, anemia).

diarrheal syndromediarrheal syndrome skin changesskin changes Fever lastedFever lasted Hemorrhagic syndromeHemorrhagic syndrome The syndrome of gastrointestinal tractThe syndrome of gastrointestinal tract HepatopankreatHepatopankreatic ic syndromesyndrome intestinal lesionintestinal lesion Syndrome Syndrome of of endocrine disordersendocrine disorders Toxic encephalopathy syndromeToxic encephalopathy syndrome Syndrome Syndrome of of cardiovascular changescardiovascular changes

Clinically distinguish light, medium and severe Clinically distinguish light, medium and severe hepatocellular failure:hepatocellular failure:

lightlight - general weakness, degradation, loss of appetite, - general weakness, degradation, loss of appetite, nausea;nausea;

medium - jaundice, drowsiness, decreased mental medium - jaundice, drowsiness, decreased mental abilities, "liver palms" appearance of vascular "stars" abilities, "liver palms" appearance of vascular "stars" on the body, hemorrhagic syndrome (bleeding from on the body, hemorrhagic syndrome (bleeding from the nose, with esophageal varices, hemorrhoids veins, the nose, with esophageal varices, hemorrhoids veins, hemorrhage);hemorrhage);

severesevere - impaired consciousness until its complete loss, - impaired consciousness until its complete loss, muscle twitching, they cramp, periodic excitation. muscle twitching, they cramp, periodic excitation. Reflexes fade, lowers blood pressure, increases Reflexes fade, lowers blood pressure, increases respiration rate, and so on.respiration rate, and so on.

MKD (mikronodulyar, portal) cirrhosis - units of the same size, MKD (mikronodulyar, portal) cirrhosis - units of the same size, with a diameter of 1-3 mm. Liver of normal size or enlarged. with a diameter of 1-3 mm. Liver of normal size or enlarged. This form of cirrhosis is often observed in alcoholism, bile duct This form of cirrhosis is often observed in alcoholism, bile duct obstruction, breach of venous outflow, hemochromatosis.obstruction, breach of venous outflow, hemochromatosis.

The initial stage (diarrheal) vascular and parenchymal The initial stage (diarrheal) vascular and parenchymal compensation. The clinic is dominated dyspeptic, compensation. The clinic is dominated dyspeptic, astenovegetativastenovegetativee syndromes. Standing is a sign of a moderate syndromes. Standing is a sign of a moderate increase in the liver.increase in the liver.

Extensive stage (ascites) accompanied by manifestations of Extensive stage (ascites) accompanied by manifestations of primary parenchymal and portal decompensation. In the initial primary parenchymal and portal decompensation. In the initial stage of clinical signs attached portal hypertension (Fig. 3), stage of clinical signs attached portal hypertension (Fig. 3), hemorrhagic syndrome, endocrine disorders, jaundice, "hepatic hemorrhagic syndrome, endocrine disorders, jaundice, "hepatic features", weight loss and atrophy of skeletal muscles. During features", weight loss and atrophy of skeletal muscles. During acute increases body temperature. The liver is enlarged, firm, acute increases body temperature. The liver is enlarged, firm, often rough, rounded edge. Increased spleen. In general blood often rough, rounded edge. Increased spleen. In general blood test show signs of moderate anemia, leukopenia, test show signs of moderate anemia, leukopenia, thrombocytopenia, and increased ESR.thrombocytopenia, and increased ESR.

Phase of severe parenchymal and portal failurePhase of severe parenchymal and portal failure (kahektychna). (kahektychna). Pronounced symptoms of the second stage. Typical is with Pronounced symptoms of the second stage. Typical is with cholestatic jaundice component severe hemorrhagic syndrome cholestatic jaundice component severe hemorrhagic syndrome (nosebleeds, distributed or pislyain'yektsiyni spontaneous (nosebleeds, distributed or pislyain'yektsiyni spontaneous ecchymosis), hepatic encephalopathy. Severe signs of portal ecchymosis), hepatic encephalopathy. Severe signs of portal hypertension: ascites, dilatation of abdominal wall ("Head of hypertension: ascites, dilatation of abdominal wall ("Head of Medusa") (Fig. 5), right pleural effusion, umbilical hernia, Medusa") (Fig. 5), right pleural effusion, umbilical hernia, bleeding from hemorrhoidal veins of esophageal varices and bleeding from hemorrhoidal veins of esophageal varices and gastric. Can a progressive decrease in the size of liver. In gastric. Can a progressive decrease in the size of liver. In general blood test show signs hgeneral blood test show signs hyypersplenizmupersplenizmuss, accelerated , accelerated ESR. ESR.

In biochemical analysis of blood - reducing total protein, albumin, In biochemical analysis of blood - reducing total protein, albumin, cholesterol, prothrombin, increased ALT, bilirubin, indicatorscholesterol, prothrombin, increased ALT, bilirubin, indicators of of thymol. In the analysis of urine - proteinuria, microhematuria, thymol. In the analysis of urine - proteinuria, microhematuria, cylindruria. Ultrasound examination of the liver reveals cylindruria. Ultrasound examination of the liver reveals hepatosplenomegaly, diffuse lesions, ascites, sudden hepatosplenomegaly, diffuse lesions, ascites, sudden expansion of portal vein, absence of respiratory fluctuations expansion of portal vein, absence of respiratory fluctuations lumen of portal vein. In Radionuclide imaging the liver are lumen of portal vein. In Radionuclide imaging the liver are hepatomegaly, diffuse lesions, diffuse weakening hatching, hepatomegaly, diffuse lesions, diffuse weakening hatching, uneven intensity figure.uneven intensity figure.

Biliary cirrhosisBiliary cirrhosis is divided into primary and secondary. The basis is divided into primary and secondary. The basis

of primary biliary cirrhosis is an autoimmune of primary biliary cirrhosis is an autoimmune disease that begins as a chronic disease that begins as a chronic nonsuppurative destructive cholangitis. Long nonsuppurative destructive cholangitis. Long time no severe symptoms. More common in time no severe symptoms. More common in women over 35 years. The most common and women over 35 years. The most common and most constant symptom is itchy skin. most constant symptom is itchy skin. Inconsistent initially it for years ahead of Inconsistent initially it for years ahead of jaundice, which gives rise to long-term jaundice, which gives rise to long-term treatment of "skin disease". Subsequently itch treatment of "skin disease". Subsequently itch becomes a constant, increasing after a warm becomes a constant, increasing after a warm bath at night. There is a dark brown bath at night. There is a dark brown pigmentation of the skin in the area of the pigmentation of the skin in the area of the blades, jaundice cholestatic type xanthelasma. blades, jaundice cholestatic type xanthelasma. Rarely is expressed mild hepatomegaly.Rarely is expressed mild hepatomegaly.

Extensive stage disease is characterized by the Extensive stage disease is characterized by the increase of jaundice, fever to febrile digits increase of jaundice, fever to febrile digits depletion until cachexia due to malabsorption in depletion until cachexia due to malabsorption in the intestines. Often there is redness of her the intestines. Often there is redness of her hands, sometimes with a yellowish tinge ("liver hands, sometimes with a yellowish tinge ("liver palms"). In some cases, changing as nails palms"). In some cases, changing as nails watch watch glassglass. . Thickening ofThickening of distal phalanges distal phalanges ("drumsticks")("drumsticks")

In end-stage (terminal) itchy skin decreases. In end-stage (terminal) itchy skin decreases. Pigmented skin thickens, coarsens, it can Pigmented skin thickens, coarsens, it can manifest as swelling in scleroderma. A violation manifest as swelling in scleroderma. A violation occurs secretion of bile malabsorption of fat-occurs secretion of bile malabsorption of fat-soluble vitamins, osteoporosis.soluble vitamins, osteoporosis.

MKD (mikronodulyar, portal) cirrhosis MKD (mikronodulyar, portal) cirrhosis - units of the - units of the same size, with a diameter of 1-3 mm. Liver of normal size or same size, with a diameter of 1-3 mm. Liver of normal size or enlarged. This form of cirrhosis is often observed in alcoholism, enlarged. This form of cirrhosis is often observed in alcoholism, bile duct obstruction, breach of venous outflow, bile duct obstruction, breach of venous outflow, hemochromatosis.hemochromatosis.

The initial stage (diarrheal) vascular and parenchymal The initial stage (diarrheal) vascular and parenchymal compensation. The clinic is dominated dyspeptic, compensation. The clinic is dominated dyspeptic, astenovegetativnogo syndromes. Standing is a sign of a astenovegetativnogo syndromes. Standing is a sign of a moderate increase in the liver.moderate increase in the liver.

Extensive stage (ascites) accompanied by manifestations of Extensive stage (ascites) accompanied by manifestations of primary parenchymal and portal decompensation. In the initial primary parenchymal and portal decompensation. In the initial stage of clinical signs attached portal hypertension (Fig. 3), stage of clinical signs attached portal hypertension (Fig. 3), hemorrhagic syndrome, endocrine disorders, jaundice, "hepatic hemorrhagic syndrome, endocrine disorders, jaundice, "hepatic features", weight loss and atrophy of skeletal muscles. During features", weight loss and atrophy of skeletal muscles. During acute increases body temperature. The liver is enlarged, firm, acute increases body temperature. The liver is enlarged, firm, often rough, rounded edge. Increased spleen. In general blood often rough, rounded edge. Increased spleen. In general blood test show signs of moderate anemia, leukopenia, test show signs of moderate anemia, leukopenia, thrombocytopenia, and increased ESR.thrombocytopenia, and increased ESR.

Blood analysis increases the activity of enzymes of Blood analysis increases the activity of enzymes of cholestasis: alkaline phosphatase, cholestasis: alkaline phosphatase, leytsynaminopeptydazy, gamma leytsynaminopeptydazy, gamma hlyutamiltranspeptydazy. hlyutamiltranspeptydazy.

Increased bilirubin slow and occurs in the later stages. Increased bilirubin slow and occurs in the later stages. Increasing the concentration of bile acids and copper Increasing the concentration of bile acids and copper content in serum and iron levels decreased. content in serum and iron levels decreased.

Typical is hyperlipidemia with increasing concentrations Typical is hyperlipidemia with increasing concentrations of cholesterol, beta-lipoproteins, phospholipids. of cholesterol, beta-lipoproteins, phospholipids.

The level of circulating immune complexes, exhibit The level of circulating immune complexes, exhibit kriohlobuliny, antimitochondrial antibodies. kriohlobuliny, antimitochondrial antibodies.

Ultrasound detects unchanged bile duct, liver biopsy in Ultrasound detects unchanged bile duct, liver biopsy in the study are nonsuppurative destructive cholangitis the study are nonsuppurative destructive cholangitis intrahepatic in the early stages of the disease, then - intrahepatic in the early stages of the disease, then - biliary cirrhosis.biliary cirrhosis.

Secondary biliary cirrhosis Secondary biliary cirrhosis is caused by prolonged is caused by prolonged violation vidtikannya bile at large intrahepatic ducts, due to violation vidtikannya bile at large intrahepatic ducts, due to strictures, stones, primary metastatic tumors. Clinic determined strictures, stones, primary metastatic tumors. Clinic determined the primary disease. It is dominated by such signs as jaundice, the primary disease. It is dominated by such signs as jaundice, diffuse hyperpigmentation of the skin, its dryness, thickening diffuse hyperpigmentation of the skin, its dryness, thickening and itching. Sometimes the forefront aholiyaand itching. Sometimes the forefront aholiya, , steatorrhea. steatorrhea. Almost always there is pain. Characterized by hyperthermia, Almost always there is pain. Characterized by hyperthermia, sweating. More pronounced than in primary biliary cirrhosis, sweating. More pronounced than in primary biliary cirrhosis, avitaminosis fat-soluble vitamins A, C, and D. The blood found avitaminosis fat-soluble vitamins A, C, and D. The blood found neutrophilic leukocytosis, accelerated erythrocyte neutrophilic leukocytosis, accelerated erythrocyte sedimentation rate.sedimentation rate.

Treatment for cirrhosis of the liverTreatment for cirrhosis of the liver Assign diet number 5 (with Pevsner). If the patient Assign diet number 5 (with Pevsner). If the patient

shows signs of hepatocellular failure, then limit the shows signs of hepatocellular failure, then limit the protein, with edema - salt. protein, with edema - salt.

Drug therapy includes drip of 5% Drug therapy includes drip of 5% GGlucose solution, lucose solution, DDextran, extran, AAlvezin, lvezin, RReohlyumanu with detoxification eohlyumanu with detoxification effect, improves microcirculation. In addition, the tools effect, improves microcirculation. In addition, the tools that affect the liver cell membrane (Essenciale, that affect the liver cell membrane (Essenciale, LLipostabil, Kars, ipostabil, Kars, HHoftiol, oftiol, RRiboksin). In portal iboksin). In portal hypertension, ascites using hypertension, ascites using PPotassium-sparing otassium-sparing diuretics (diuretics (VVeroshpiron, eroshpiron, TTriamterene), which can be riamterene), which can be combined with Saluretics (combined with Saluretics (FFurosemide, urosemide, UUrehit, rehit, OOksodomin), beta-blockers. The use of diuretics ksodomin), beta-blockers. The use of diuretics requires periodic prescribing potassium (requires periodic prescribing potassium (AAsparcam, sparcam, Panangin). Assign vitamins A, D, E, C, B vitamins to Panangin). Assign vitamins A, D, E, C, B vitamins to reduce itching - reduce itching - CCholestyramine, holestyramine, CCarbon and arbon and SSilicon ilicon sorbents.sorbents.

When symptoms of encephalopathy apply glutamic When symptoms of encephalopathy apply glutamic acidacid,, OOrnitsetyn, rnitsetyn, HHoftiol, oftiol, PPurslane, urslane, AAntibacterials, ntibacterials, PPlazmaforez, lazmaforez, HHemosorbtion. When ascites emosorbtion. When ascites intravenously administered native plasma albumin, intravenously administered native plasma albumin, which increase the osmotic pressure of the plasma, which increase the osmotic pressure of the plasma, improve metabolism in liver cells.improve metabolism in liver cells.

During resistant ascites, which defies adequate During resistant ascites, which defies adequate therapy accession hepatorenal syndrome threats therapy accession hepatorenal syndrome threats abdominal bleeding apply parantsentez (removed no abdominal bleeding apply parantsentez (removed no more than three liters of fluid).more than three liters of fluid).

Unfavorable prognosis. The average life span of Unfavorable prognosis. The average life span of patients with cirrhosis 4-6 years. It remains the longest patients with cirrhosis 4-6 years. It remains the longest performance with biliary cirrhosis, less - in portal and performance with biliary cirrhosis, less - in portal and postnekrotyc cirrhosis.postnekrotyc cirrhosis.

Prevention. First elimination or limitation of etiological Prevention. First elimination or limitation of etiological factors, timely diagnosis and treatment of chronic factors, timely diagnosis and treatment of chronic hepatitis and liver.hepatitis and liver.

Thanks for your Thanks for your attention!attention!