Adenoma bds treatment. What is the papilla of Vater, and what diseases is it susceptible to? Diseases of the major duodenal papilla

The content of the article

In the structure of the incidence of malignant neoplasms, cancer of the major duodenal papilla accounts for about 1%. There are no gender differences in incidence. Risk factors that can lead to the development of cancer include the presence of hyperplastic changes in the area of ​​the papilla of Vater - hyperplastic orifice polyps, adenomas, glandular-cystic hyperplasia of the transitional fold of the major duodenal papilla, adenomyosis.
Major duodenal papilla cancer most often presented as an exophytic form that bleeds easily on instrumental palpation. The tumor has the appearance of a polyp, papilloma or fungal growth, sometimes a “cauliflower” appearance. The obstructive jaundice that develops may be remitting in nature. Rarer endophytic forms of cancer cause persistent jaundice. The macro- and microscopically defined boundaries of the tumor in cancer of the major duodenal papilla coincide much more often than in exocrine pancreatic cancer or cancer of the common bile duct. In tumor tissue, individual and grouped endocrine cells of a tumor nature are often identified, having a cylindrical, triangular and spindle-shaped shape. Such cells are found in the greatest numbers in highly differentiated tumors - papillary and tubular adenocarcinomas. As anaplasia increases, the frequency of detection of endocrine cells decreases until they are completely absent.
Cancer of the major duodenal papilla has a pronounced infiltrating growth: already by the time jaundice appears, there may be invasion of the wall of the duodenum, pancreas, metastases in regional, juxtaregional lymph nodes and distant metastases. In most cases, the tumor grows into the wall of the common bile duct and completely obstructs its lumen. But obstruction or stenosis may be incomplete - disturbances in the neuromuscular apparatus of the duct and swelling of the mucous membrane are quite enough to significantly reduce or completely stop the flow of bile into the duodenum. Biliary hypertension develops, in which all overlying parts of the biliary tree undergo dilatation. There is a real threat of cholangitis and cholangiogenic liver abscesses. In the liver itself, the mechanisms of its cirrhotic transformation are launched. Hypertension in the pancreatic ducts, caused by stenosis or obstruction of the main pancreatic duct by a pancreatic tumor, leads to degenerative-dystrophic and inflammatory changes in the pancreatic parenchyma. An increase in tumor size can lead to deformation of the duodenum. In this case, obstruction of the intestinal lumen by a tumor, as a rule, does not lead to decompensation of intestinal patency. A more common complication after obstructive jaundice is tumor disintegration with intraintestinal bleeding.
The size of the tumor during the period of obstructive jaundice syndrome and surgical treatment is from 0.3 cm. The paths of lymphogenous metastasis are the same as for cancer of the head of the pancreas and the common bile duct. The frequency of detection of metastases in regional and juxtaregional lymph nodes in LBD cancer at the time of surgery is 21-51%. Characteristically, one or two groups of lymph nodes of the regional collector are affected.

Clinical and anatomical classification of cancer of the major duodenal papilla according to TNM of the International Union against Cancer (6th edition, 2002)

Clinical picture and diagnosis of cancer of the major duodenal papilla

Treatment of cancer of the major duodenal papilla

Cancer of the papilla of Vater develops due to the transformation of the cells of the pancreatic or bile duct, next to which it is located, or the cells of the epithelium of the duodenum. The tumor grows slowly. The pathological anatomy is as follows: visually the neoplasm resembles cauliflower inflorescences or papilloma, may have the shape of a mushroom, and in rare cases endophytic forms are observed. The tumor quickly ulcerates; at the time of removal, a diameter of 3 mm is most often recorded.

For cancer of the duodenal papilla (major duodenal papilla), it is common to invade the bile flow. The affected area is the walls of the duodenum and the pancreas. There is a threat (21–51%) of the appearance of lymphogenous metastases. Distant metastases can develop in the liver, adrenal gland, lungs, bones, and brain, but this occurs in rare cases.

The growth of a BDS tumor into the intestinal wall can cause bleeding, leading to anemia. Upon palpation, the patient can clearly feel the enlarged gallbladder under the liver.

At the moment, scientists find it difficult to accurately name the causes of the development of a tumor of the papilla of Vater, but some risk factors have been identified.

• Firstly, they include heredity. A genetic mutation of KRAS or several cases of familial polyposis diagnosed in relatives increases the risk of developing the disease.
• Secondly, the risk increases due to chronic pancreatitis, diabetes mellitus and diseases of the hepatobiliary system, as well as due to malignancy of the cells of the nipple itself.

Men suffer from the disease more often (2:1). Carcinoma usually appears around the age of 50. Working in hazardous chemical production increases the risk of developing the disease.

Etiology and pathogenesis

The etiology and pathogenesis of tumors of the major duodenal papilla are unknown. It is assumed that factors contributing to the development of duodenal papillitis also cause the development of benign tumors of the major duodenal papilla.

Most tumors rarely regenerate. A well-known exception is a portion of villous adenomas and leiomyomas, which sometimes reach relatively large sizes (2-3 cm or more) and cause disruption of the outflow of bile with pain and jaundice. In some cases, these relatively large tumors degenerate.

More often, the development of papillomas in the area of ​​the BDS is observed when the common bile duct and the pancreatic duct enter the cavity of the duodenum separately (without the formation of the hepatic-pancreatic ampulla). It is believed that this anatomical structure contributes to traumatization of the area of ​​the mouths of the ducts during intestinal peristalsis, the development of congestive, inflammatory, fibrous and hyperplastic processes.

Clinical picture

An early and leading sign of a tumor process is obstructive jaundice, which is often remitting in nature. Courvasier's symptom is positive in 60% of cases. Differential diagnosis is carried out with other tumors of the biliopancreatoduodenal zone (pancreatic head cancer, bile duct cancer and duodenal tumors).

It is necessary to exclude metastatic damage to the lymph nodes of the pancreaticoduodenal region in cancer of the lung, breast, stomach, etc. Often the cause of obstructive jaundice can be damage to the pancreaticoduodenal region in lymphomas. The most informative method for diagnosing cancer of the major duodenal papilla remains endoscopy with targeted biopsy.

The manifestations of benign neoplasms of the BDS are the same. In the early stages of the process, they depend not so much on the histological structure of the tumor, but on the degree of disruption of the separation of bile and pancreatic secretion, dysfunction of the sphincter of Oddi and duodenal motility. A typical picture is of recurrent chronic cholecystitis, pancreatitis, and secondary dysfunction of the sphincter of Oddi.

Less commonly, the disease manifests itself as recurrent mechanical jaundice and hepatic colic. Sometimes there are symptoms of chronic cholestasis in the form of prolonged skin itching, disorders of cavity digestion in the duodenum and small intestine, and chronic constipation. Long-term and increasing mechanical subhepatic cholestasis, characteristic of LDS cancer, is usually not present in benign neoplasms

Clinical and anatomical classification of cancer of the major duodenal papilla according to TNM of the International Union against Cancer (6th edition, 2002)

Tis - carcinoma in situ

TI - tumor limited to the major duodenal papilla or sphincter of Oddi

T2 - tumor extends to the wall of the duodenum

T3 - the tumor spreads to the pancreas

T4 - Tumor has spread to tissue around the head of the pancreas or other structures or organs

N1 - metastases in regional lymph nodes

M1 - distant metastases

Stage IA: T1NOMO

Stage IB: T2N0M0

Stage NA: T3N0M0

Stage IIB: T1-3N1M0

Stage III: T4N0-1 MO

Stage IV.T1-4N0-1M1

There is no generally accepted classification of benign tumors of the major duodenal papilla.

The classification of malignant tumors of the BDS according to the TNM system is as follows.

T1 - the size of the tumor does not exceed 1 cm, the tumor extends beyond the papilla.

T2 - tumor no more than 2 cm, involved in the process of the mouth of the common bile duct and pancreatic duct, but without infiltration of the posterior wall of the duodenum.

T3 - tumor up to 3 cm, grows into the posterior wall of the duodenum, but without invasion into the pancreas.

T4 - the tumor spreads beyond the duodenum, grows into the head of the pancreas, and invades the vessels.

Ny - the presence of lymphogenous metastases is not known.
Na - single retroduodenal lymph nodes are affected.
Nb - parapancreatic lymph nodes are affected.
Ne - periportal, para-aortic or mesenteric lymph nodes are affected.

M0 - no distant metastases.
M1 - there are distant metastases.

There are several morphological types of malignant tumors of the BDS.

Adenocarcinoma of the BDS.

Papillary cancer. Exophytic growth into the lumen of the papilla and duodenum is characteristic. The tumor is represented by glandular-like complexes of small size with a well-defined stroma. The complexes are cavities lined with tall columnar epithelium with a thickened basement membrane.

Scirrhosis form. The tumor is small in size with a predominant spread along the common bile duct and into surrounding tissues. The neoplasm contains fibrous tissue rich in collagen fibers with a pronounced vascular network, among which small polymorphic cancer cells are visible, sometimes forming cavities and cysts; cell nuclei of various sizes show a large number of mitoses, including pathological ones.

Mucous cancer. Characteristic is the growth into the lumen of the papilla of glandular structures formed by prismatic cells with a large amount of pink mucus in the apical sections. The mitotic activity of cancer cells is high.

Adenocarcinoma arising from the epithelium of the duodenum. A large number of glandular structures of round, oval or convoluted shape are revealed, devoid of excretory ducts and in places overflowing with mucus. These structures infiltrate the submucosal and muscular membranes of the duodenum. The epithelium is atypical, predominantly cubic, sometimes multirow prismatic; large mast cells with pronounced granularity are present.

Of all the listed malignant neoplasms of the BDS area, adenocarcinoma develops most often. BDS carcinomas are characterized by slower growth and a more favorable prognosis than pancreatic cancer.
Macroscopically, three forms of BDS cancer are distinguished: polyposis, infiltrative and ulcerative. Usually the tumor is small (up to 1.5 cm in diameter) and has a stalk. The process does not extend beyond the papilla for a long time.

The polypous form can lead to obstruction of the lumen of the abdominal joint (see Fig. 5-45), and the infiltrative form can lead to its stenosis. In addition, the tumor can infiltrate the wall of the duodenum with the formation of a nodular form. This form of tumor is characterized by the absence of changes in the mucous membrane above the tumor, so a superficial biopsy may not yield results.

Infiltration of the BDS by the tumor process occurs through the submucosal and muscular membranes of the papilla, subsequently through the wall of the common bile duct, pancreatic tissue, and duodenal wall. Typically, metastases to the peripancreatic lymph nodes occur when the tumor diameter is more than 15 mm.

A long-term tumor process is characterized by increasing cholestasis, secondary cholecystitis, development of congestive gallbladder, choledocholithiasis, cholangitis, secondary biliary hepatitis, liver cirrhosis, biliary-dependent obstructive pancreatitis.

Damage to the duodenum by the tumor process can lead to its severe deformation, the development of secondary dynamic and mechanical obstruction (duodenostasis), and ulceration can lead to bleeding. Clinical picture

Cancer of the BDS area can occur in several clinical forms:
choleis-like variant (with typical biliary colic);
cholangitis (without colic, with skin itching, jaundice, low-grade fever);
gastric (dyskintic) with secondary gastric dyspepsia.

Once occurring, jaundice in BDS cancer becomes permanent with a tendency to worsen, but temporary (false) improvements are possible], mainly due to recanalization of the duct during tumor disintegration, or against the background of anti-inflammatory therapy by reducing secondary edema of the mucosa.

Characterized by a pronounced dyspeptic syndrome associated with impaired cavity digestion in the duodenum and small intestine due to impaired outflow of bile and pancreatic secretions. Patients gradually lose weight, even to the point of cachexia.

Symptoms of cancer of the major duodenal papilla

The first symptom is obstructive jaundice due to narrowing of the bile duct. Initially, it moves and becomes more stable as the disease progresses. During this phase, symptoms such as severe pain, profuse sweating, chills and itching are also observed.

In most cases, cancer of the major duodenal papilla leads to sudden weight loss and vitamin deficiency. Indicators may also include symptoms such as digestive disorders: bloating, pain, diarrhea (grey stool). If the disease is advanced, fatty stool may appear.

Clinical picture and diagnosis of cancer of the major duodenal papilla

Diagnosis is carried out taking into account clinical signs, most often obstructive jaundice syndrome, X-ray and endoscopic examination data with biopsy. However, the stage of the process can often be determined only during surgery (metastases are detected in the lymphatic tract and surrounding organs, often in the head of the pancreas).

X-ray examination of malignant neoplasms of the duodenum reveals a defect in the filling of the duodenum in the zone of its descending part along the internal contour. The size of the defect is usually small (up to 3 cm), its contours are uneven, and the relief of the mucous membrane is disturbed. Particular attention should be paid to the rigidity of the intestinal wall at the site of the filling defect. Diagnosis is aided by tight filling of the intestine with barium sulfate in conditions of hypotension, as well as double contrasting of the intestine.

The most common early endoscopic symptom is an increase in the size of the BDS, ulcerations in its area, papillary or tuberous formations (see Fig. 5-46). Often the papilla takes on a crimson-red color. During decay, the amount of BDS may be small, however, as a rule, a large area of ​​ulceration and infiltration of surrounding tissues is revealed.

During endoscopy, special attention should be paid to examining the condition of the longitudinal fold of the duodenum. In case of BDS cancer, bulging of its oral part is often detected, without gross disturbances of the relief of the mucous membrane, characteristic of infiltrating growth of the BDS tumor and the presence of biliary hypertension.

In some cases, ERCP, MRCP, and EUS help diagnose BDS cancer; These methods make it possible to identify damage to the ducts, the transition of the process to the pancreas.

In case of unsuccessful attempts to contrast the ducts due to tumor obstruction of the orifice of the BDS, laparoscopic or percutaneous transhepatic cholecystocholangiography is used. As a rule, dilatation of the bile ducts with a “break” of the common bile duct in the duodenum area is detected.

Differential diagnosis in the presence of obstructive jaundice syndrome is carried out with benign tumors of the obstructive jaundice, choledocholithiasis, stenotic papillitis, tumors of the head of the pancreas, autoimmune pancreatitis, etc.

With extensive tumor infiltration and ulceration of the LBD area, secondary damage to the papilla most often occurs due to the spread of cancer of the head of the pancreas. The correct diagnosis can be made by CT, MRI, ERCP, ultrasound by identifying changes in the structure of the gland, indicating its primary tumor lesion.

Diagnosis of all benign neoplasms of the BDS is based on the clinical picture, X-ray and endoscopic examination. Endoscopists have a rule: when examining the AP K, always study the area of ​​the BDS. Differential diagnosis is carried out between papillomas and the papillary form of BDS cancer.

Diagnosis of a malignant tumor of BDS is often difficult due to the similarity of symptoms of various diseases. For example, stenotic duodenal papillitis (BD stenosis) may have a number of similar symptoms, in particular the development of jaundice. Adenoma of the intestinal tract also leads to the proliferation of intestinal tissue.

Diagnosis is complicated by inflammatory processes associated with cancer. Often, such symptoms provide grounds for diagnosing pancreatitis, cholecystitis, etc. After a course of antibiotics, the inflammation is relieved, which is mistakenly perceived as recovery. Inflammation can also occur due to papillitis of the BDS.

In addition, the complex anatomy of the papilla of Vater often makes the diagnosis difficult. To make an accurate diagnosis, data obtained from an objective examination, duodenoscopy, cholangiography (intravenous or transhepatic), probing and other studies are usually used.

The main diagnostic method is duodenoscopy with targeted biopsy. If the tumor grows exophytically, it is clearly visible (the accuracy of the study is 63–95%). Failures are possible due to stricture of the ducts, due to which the contrast agent does not spread well.

An X-ray examination of the duodenum is often used. In the presence of a tumor of the abdominal cavity, disturbances in the movement of the contrast agent are visualized and changes in the anatomical shape of the walls or filling of the intestine become clearly visible. This method is also used to diagnose duodenal papillitis.

In some cases, when the BDS is not reliably visualized and standard examinations do not allow an accurate diagnosis, this means the need for laparotomy - the nipple is cut to collect tissue.

In some cases, endoscopy or gastroscopy of the stomach with examination of the gastrointestinal tract is used.

In this video, a specialist will talk about the disease of the papilla of Vater and the difficulties of diagnosing the disease.

Treatment

At the first stage, obstructive jaundice is relieved. The only treatment for BDS cancer is surgery. Surgical treatment is performed in the scope of gastropancreaticoduodenal resection (Whipple operation). Transduodenal papillectomy is performed only in elderly patients due to the high risk of local recurrence of the disease (50-70%).

Treatment is usually conservative, aimed at stopping the exacerbation of duodenal papillitis. Only multiple or large tumors that impede the outflow of bile and pancreatic secretions serve as the basis for resection of the major duodenal papilla. Very rarely is there a need for a larger scale operation.

Patients with benign tumors of the major duodenal papilla require dynamic endoscopic examination.

For small tumors in the early stages, transduodenal papillectomy with a biliodigestive bypass anastomosis is usually used. The five-year survival rate for this operation is 9-51%. You can perform extended papillectomy according to N.N. Flea or pancreaticoduodenectomy.

In case of advanced tumor processes, operations to drain the ducts of the abdominal wall (EPST, application of various cholecystodigestive anastomoses) are more often performed. However, timely radical surgical treatment ensures a five-year survival rate of 40%.

For palliative purposes in patients with inoperable BDS cancer, due to its low morbidity and the possibility of re-execution in case of relapses of obstructive jaundice, the use of EPST with retrograde prosthetics (stenting) of the bile ducts is recommended.

The data presented indicate the importance of timely diagnosis of tumor lesions in the BDS area: the earlier the tumor process is verified, the more radical and less traumatic it is possible to operate on these patients.

Maev I.V., Kucheryavyi Yu.A.

Treatment is surgical. For papilloma juze, EPST or endoscopic papillomectomy is performed. Small adenomas are usually removed endoscopically. For large tumors, papillotomy or papilloectomy with papilloplasty is performed, and less commonly, pancreaticoduodenectomy. If malignancy is suspected, pancreatoduodenal resection is performed; if the process is inoperable, a biliodigestive anastomosis is performed.

Treatment must be prompt. The main method is surgical intervention. The patient undergoes gastropancreatoduodenal resection. This type of treatment is difficult for the body and is allowed for patients after checking their level of exhaustion, the amount of protein in the blood and other indicators.

If cancer treatment begins at stage I or II, the survival rate is 80–90%. At stage III, it also makes sense to start treatment: the five-year life expectancy in this case reaches 5–10%.

If the patient's health condition does not allow radical therapy, treatment consists of conditionally radical operations, for example pancreaticoduodenectomy.

If there is no hope for the patient's recovery, palliative therapy is used, which is aimed at alleviating symptoms. In particular, they ensure the outflow of bile using various types of anastomoses. Such treatment not only alleviates suffering, but in some cases can prolong the patient’s life.

Prevention

Risk factors for developing the disease are smoking and alcoholism.

It is difficult to overestimate the importance of proper nutrition. It should be taken into account that the condition of BDS is adversely affected by both overeating and abuse of junk food (smoked, fried, etc.), as well as malnutrition, in particular grueling diets or fasting, which are carried out at your own discretion without consulting a doctor. If you have gastrointestinal diseases (duodenitis, cholecystitis, etc.), you must strictly follow the prescribed diet.

Frequent stress and chronic fatigue should also be avoided.

Observations from practice

ON THE. Postrelov, R.L. Aristov, S.A. Vinnichuk, A.I. Markov, A.V. Rastegaev

ADENOMA OF THE MAIN DUODENAL PAPILLA

Departments of Surgical Diseases with a course of pediatric surgery (headed by Prof. E.G. Topuzov) and pathological anatomy (headed by Prof. N.M. Anichkov) of the State Educational Institution of Higher Professional Education “St. Petersburg State Medical Academy named after. I.I. Mechnikov Roszdrav"

Key words: adenoma of the major duodenal papilla.

In the duodenum, the most common location of an adenomatous polyp is the ampullary part of the major duodenal papilla, in which more than 60% of duodenal adenomas are found. In 25-65% of cases, adenoma is combined with cancer. In the same percentage, over time, according to diagnostic and treatment endoscopy, it transforms into well-differentiated adenocarcinoma. The risk of malignancy is reflected by the classification of Spigelman (2002), according to which the essential features are: the number of polyps (1-4, 5-20, more than 20), their size in millimeters (1-4, 5-10, more than 10), histological characteristics ( tubular, tubular-villous, villous) and the degree of dysplasia (low - high) in a three-dimensional scoring. Considering the danger of malignancy, it seems advisable, when initially identifying an adenoma of the major duodenal papilla, to intraoperatively perform a total papillectomy with wide excision of the polyp stalk at the site of the transition of the bile and main pancreatic duct into the duodenum.

An example of such tactics can be the following clinical observation.

Patient T., 45 years old, was hospitalized at the Clinic of Surgical Diseases No. 1 of St. Petersburg State Medical Academy named after. I.I. Mechnikova on March 17, 2008 due to obstructive jaundice.

At the time of hospitalization, she complained of pain in the epigastric region, icteric sclera, moderate weakness, and decreased appetite. I considered myself sick for about 3 months.

Objectively: upon admission the condition is of moderate severity, sclera, skin, mainly hair

the sternum of the head is subicteric. Slight pain on palpation in the epigastric region. Laboratory research methods: hemoglobin - 98 g/l; AST - 82 U/l; ALT - 74 U/l; blood bilirubin - 62 µmol/l. Echophagogastroduodenoscopy - the longitudinal fold of the duodenum is thickened and elongated; from the mouth of the major duodenal papilla - the growth of a large formation, with a diameter of at least 35 mm, with a loose, hyperemic surface and foci of destruction. Histology dated March 20, 2008: fragments of tubular-papillary adenoma without signs of malignant growth. MRI of the abdominal organs: moderate expansion of the intrahepatic

Histological examination of adenoma (explanation in the text).

Volume 170 No. 1

Adenoma of the major duodenal papilla

of the bile ducts, the common bile duct is 11 mm, the gallbladder is 12x4.5 cm, in the pancreaticoduodenal zone a volumetric formation with a diameter of about 40 mm is determined, located in the lumen of the duodenum. The main pancreatic duct is tortuous and dilated to 5 mm.

Operation (04/02/2008): cholecystectomy, papillectomy. The liver is cholestatic; the gallbladder is tense and enlarged. In the lumen of the lower horizontal branch of the duodenum, a displaceable tumor measuring 4x5 cm is detected. Cholecystectomy. Longitudinal duodenotomy. Papillectomy with implantation of the common bile and main pancreatic ducts into the lumen of the duodenum. The tumor was removed within healthy tissues with excision of the wall of the duodenum measuring 2.0x1.5 cm. Histological examination: large adenoma (size 5.5x4x3 cm) on a wide base, tubular structure, with glands lined with cubic and columnar epithelium without cellular and nuclear polymorphism, cystic transformation of some glands, focal lymphocytic infiltration in the stroma

(stage II), fibrous pedicle with thick-walled sclerosed vessels (picture).

The postoperative period proceeded smoothly. The sutures were removed on the 10th day. The patient was discharged from the clinic in satisfactory condition on April 18, 2008. Diagnosis: adenoma of the major duodenal papilla. The observation period is 2 years. Examined clinically and endoscopically. Almost healthy.

BIBLIOGRAPHICAL LIST

1. Briskin B.S., Ektov P.V., Titova G.P., Klimenko Yu.F. Benign tumors of the major duodenal papilla // Ann. hir. Hepatol.-2003.-No. 22.-S. 229-231.

2. Paltsev M.A., Anichkov N.M. Atlas of pathology of human tumors.-M.: Medicine, 2005.-424 p.

3. Groves C.J., Saunders V.R., Spigelman A.D., Phillips Y.K. Duodenal cancer in patients with familial adenomatous polyposis (FAP): results of a 10 year prospective study // J. gastroenterology & hepatology.-2002.-Vol. 50, no. 5.-P. 636-641.

Dysfunction of the major duodenal papilla (MDP) is a functional disease manifested by a violation of the mechanisms of relaxation and contraction of the sphincter of Oddi with a predominance of increased tone and spasm (hypermotor, hyperkinetic) or relaxation and atony (hypomotor, hypokinetic), without organic and inflammatory changes, causing disruption of bile flow and pancreatic juice into the duodenum.

Dyskinesia of the bile ducts usually occurs as a result of a violation of the neurohumoral regulation of the mechanisms of relaxation and contraction of the sphincters of Oddi, Martynov-Lutkens and Mirizzi. In some cases, atony of the common bile duct and spasm of the sphincter of Oddi predominate due to an increase in the tone of the sympathetic part of the autonomic nervous system, in others - hypertension and hyperkinesia of the common bile duct during relaxation of the above-mentioned sphincter, which is associated with excitation of the vagus nerve. In clinical practice, hypermotor dyskinesia is more common. The reason is psychogenic effects (emotional stress, stress), neuroendocrine disorders, inflammatory diseases of the gallbladder, pancreas, duodenum. BDS dysfunctions are often combined with hypermotor and hypomotor dyskinesias of the gallbladder.

Classification:

1. Dysfunction of the hypertensive type:

2. Hypotonic type dysfunction (sphincter of Oddi insufficiency):

• with hypermotor, hyperkinetic dyskinesia of the gallbladder;
• with hypomotor, hypokinetic dyskinesia of the gallbladder.

Clinic:

• dull or sharp, severe, persistent pain in the epigastric region or right hypochondrium with irradiation to the right shoulder blade, left hypochondrium, may be of a girdling nature with irradiation to the back;
• not accompanied by fever, chills, enlarged liver or spleen;
• pain is associated with eating, but may appear at night;
• may be accompanied by nausea and vomiting;
• the presence of idiopathic recurrent pancreatitis;
• exclusion of organic pathology of the organs of the hepatopancreatic region;
• clinical criterion: recurrent attacks of severe or moderate pain lasting more than 20 minutes, alternating with pain-free intervals, repeated for at least 3 months, disrupting work activity.

Clinical types of BDS dysfunction:

1. Biliary (more common): characterized by pain in the epigastrium and right hypochondrium, radiating to the back, right scapula:

• • an increase in aspartate aminotransferase (AST) and/or alkaline phosphatase (ALP) by 2 or more times in a 2-fold study;
  • delayed removal of contrast agent from the bile ducts during endoscopic retrograde cholangiopancreatography (ERCP) for more than 45 minutes;
  • dilation of the common bile duct more than 12 mm;
• option 3 - an attack of pain of the “biliary” type.

2. Pancreatic - pain in the left hypochondrium, radiates to the back, decreases when bending forward, does not differ from pain in acute pancreatitis, may be accompanied by an increase in the activity of pancreatic enzymes in the absence of reasons (alcohol, cholelithiasis):

• option 1 - pain syndrome in combination with the following laboratory and instrumental signs:
  • increased activity of serum amylase and/or lipase 1.5-2 times higher than normal;
  • dilation of the pancreatic duct during ERCP in the head of the pancreas is over 6 mm, in the body - 5 mm;
  • the time taken for the contrast agent to be removed from the ductal system in the supine position is exceeded by 9 minutes compared to the norm;
• option 2 - pain in combination with 1-2 of the above laboratory and instrumental signs;
• option 3 - an attack of pain of the “pancreatic” type.

3. Mixed - pain in the epigastrium or girdles, can be combined with signs of both biliary and pancreatic types of dysfunction.

The diagnosis of “hypertension of the sphincter of Oddi” is made in cases where the closed sphincter phase lasts longer than 6 minutes, and the secretion of bile from the common bile duct is slow, intermittent, and sometimes accompanied by severe colicky pain in the right hypochondrium.

Insufficiency of BDS is most often secondary, in patients with cholelithiasis, chronic calculous cholecystitis, due to the passage of a calculus, inflammation of the pancreas, duodenal mucosa, and duodenal obstruction. With duodenal intubation, the closed phase of the sphincter of Oddi is reduced to less than 1 minute or the absence of the sphincter closing phase is noted, the absence of a shadow of the gallbladder and ducts during cholecystocholangiography, the reflux of a contrast agent into the bile ducts during fluoroscopy of the stomach, the presence of gas in the bile ducts, a decrease in residual pressure during cholangiomanometry, reducing the time of arrival of the radiopharmaceutical into the intestine by less than 15-20 minutes with hepatobilis scintigraphy.

Diagnostics

1.Transabdominal ultrasonography. The ultrasound screening method of examination occupies a leading place in the diagnosis of dyskinesias (Table) and makes it possible to identify with high accuracy:

• features of structural changes in the gallbladder and bile ducts, as well as the liver, pancreas (shape, location, size of the gallbladder, thickness, structure and density of the walls, deformations, presence of constrictions);
• the nature of the homogeneity of the gallbladder cavity;
• the nature of the intraluminal contents, the presence of intracavitary inclusions;
• changes in the echogenicity of the liver parenchyma surrounding the gallbladder;
• contractility of the gallbladder.

Ultrasound signs of dyskinesia:

• increase or decrease in volume;
• heterogeneity of the cavity (hyperechoic suspension);
• decreased contractile function;
• with deformation of the gallbladder (kinks, constrictions, septa), which may be a consequence of inflammation, dyskinesias are much more common;
• other signs indicate an inflammatory process, past inflammation, cholelithiasis, and serve for differential diagnosis.

2. Ultrasound cholecystography. Makes it possible to study the motor-evacuation function of the gallbladder within 1.5-2 hours from the moment of taking a choleretic breakfast until the initial volume is achieved. Normally, 30-40 minutes after stimulation, the gallbladder should shrink by 1/3-1/2 of its volume. An extension of the latent phase to more than 6 minutes indicates an increase in the tone of the sphincter of Oddi.

3. Dynamic hepatobiliscintigraphy. It is based on recording time indicators of the passage of short-lived radionuclides along the biliary tract. Allows you to evaluate the absorption-excretory function of the liver, the storage-evacuation function of the gallbladder (hypermotor, hypomotor), the patency of the terminal part of the common bile duct, to identify obstruction of the bile ducts, insufficiency, hypertonicity, spasm of the sphincter of Oddi, stenosis of the BDS, to differentiate organic and functional disorders using tests with Nitroglycerin or Cerucal. With hypertonicity of the sphincter of Oddi, there is a slowdown in the flow of the drug into the duodenum after a choleretic breakfast. This method most accurately allows you to determine the type of dyskinesia and the degree of functional impairment.

4. Fractional chromatic duodenal sounding. Gives information about:

• tone and motility of the gallbladder;
• tone of the sphincter of Oddi and Lutkens;
• colloidal stability of cystic and hepatic bile fractions;
• bacteriological composition of bile;
• secretory function of the liver.

5. Gastroduodenoscopy. Allows you to exclude organic lesions of the upper gastrointestinal tract, assess the condition of the obstructive system, and the flow of bile.

6. Endoscopic ultrasonography. Allows you to more clearly visualize the terminal section of the common bile duct, BDS, head of the pancreas, the confluence of the Wirsung duct for the purpose of diagnosing stones, differential diagnosis of organic lesions of the BDS and hypertonicity.

7.Endoscopic retrograde cholangiopancreatography. The method of direct contrasting of the biliary tract allows us to identify the presence of stones, stenosis of the biliary tract, dilatation of the biliary tract, perform direct manometry of the sphincter of Oddi, and is of great importance in the differential diagnosis of organic and functional diseases.

8. CT scan. Allows you to identify organic damage to the liver and pancreas.

9. Laboratory diagnostics. In case of primary dysfunctions, laboratory tests do not have any deviations from the norm, which is important for differential diagnosis. A transient increase in the level of transaminases and pancreatic enzymes can be observed after an attack with dysfunction of the sphincter of Oddi.

Treatment

The main goal is to restore the normal outflow of bile and pancreatic juice into the duodenum.

Basic principles of treatment:

1) normalization of the processes of neurohumoral regulation of bile secretion mechanisms - treatment of neuroses, psychotherapy, elimination of hormonal disorders, conflict situations, rest, proper diet;
2) treatment of diseases of the abdominal organs, which are the source of pathological reflexes to the muscles of the gallbladder and bile ducts;
3) treatment of dyskinesia, which is determined by its form;
4) elimination of dyspeptic manifestations.

Treatment for hypertensive dyskinesia

1. Elimination of neurotic disorders, correction of autonomic disorders:

• sedatives: herbal infusions of valerian and motherwort, Corvalol, Novo-passit - have a sedative effect, normalize sleep, relax smooth muscles;
• tranquilizers: Rudotel (medazepam) - 5 mg in the morning and afternoon, 5-10 mg in the evening; Grandaxin - 50 mg 1-3 times a day;
• psychotherapy.

2. Diet therapy:

• diet with frequent (5-6 times a day), split meals;
• exclude alcoholic and carbonated drinks, smoked, fried, fatty, spicy, sour foods, seasonings, animal fats, oils, concentrated broths (diet No. 5);
• exclude or limit the consumption of egg yolks, baked goods, creams, nuts, strong coffee, tea;
• buckwheat porridge, millet, wheat bran, cabbage are shown.

3. Antispasmodics:

• No-spa (drotaverine) - 40 mg 3 times a day for 7-10 days to 1 month, to relieve a painful attack - 40-80 mg, or 2-4 ml of a 2% solution intramuscularly, intravenously drip in physiological sodium chloride solution ;
• Papaverine - 2 ml of 2% solution intramuscularly, intravenously; in tablets 50 mg 3 times a day;
• Duspatalin (mebeverine) - 200 mg 2 times a day 20 minutes before meals.

4. Prokinetics: Cerucal (metoclopramide) - 10 mg 3 times a day 1 hour before meals.

5. Odeston (hymecromone) - has an antispasmodic effect, relaxes the sphincter of the gallbladder, bile ducts and sphincter of Oddi, without affecting the motility of the gallbladder - 200-400 mg 3 times a day for 2-3 weeks.

Treatment for hypotonic dyskinesia

1. Diet therapy:

• fractional meals - 5-6 times a day;
• the diet includes products that have a choleretic effect: vegetable oil, sour cream, cream, eggs;
• The menu should include a sufficient amount of fiber, dietary fiber in the form of fruits, vegetables, rye bread, since regular bowel movements have a tonic effect on the bile ducts.

2. Choleretics - stimulate the bile-forming function of the liver:

• Festal - 1-2 tablets 3 times a day after meals;
• Kholosas, Kholagol - 5-10 drops 3 times a day 30 minutes before meals, a decoction of choleretic herbs - 3 times a day - 10-15 days.

3. Having antispasmodic and choleretic effects:

• Odeston - 200-400 mg 3 times a day - 2-3 weeks. Effective in cases of simultaneous presence of hypomotor dysfunction of the gallbladder and hypermotor dysfunction of the sphincter of Oddi;
• Essentiale Forte N - 2 capsules 3 times a day.

4. Cholekinetics - increase the tone of the gallbladder, reduce the tone of the bile ducts:

• 10-25% solution of magnesium sulfate, 1-2 tablespoons 3 times a day;
• 10% sorbitol solution, 50-100 ml 2-3 times a day, 30 minutes before meals;
• herbal products.

5. Prokinetics:

• Cerucal (metoclopramide) - 10 mg 3 times a day 1 hour before meals;
• Motilium (domperidone) - 10 mg 3 times a day 30 minutes before meals.

6. “Blind tubage” - duodenal intubation and duodenal lavage with warm mineral water, administration of a 20% sorbitol solution, which reduces or eliminates sphincter spasm, increases the outflow of bile - 2 times a week.

Odeston is effective in cases of simultaneous presence of hypomotor dysfunction of the gallbladder and hypermotor dysfunction of the sphincter of Oddi. With a combination of hyperkinetic, normokinetic dysfunction of the gallbladder and hyperkinetic dysfunction of the sphincter of Oddi, the effectiveness of No-shpa therapy reaches 70-100%. When hypokinetic dysfunction of the gallbladder and hyperkinetic sphincter of Oddi are combined, the appointment of Cerucal or Motilium is indicated, possibly in combination with No-shpa. When hypermotor dysfunction of the gallbladder and hypomotor sphincter of Oddi are combined, the administration of artichoke extract 300 mg 3 times a day is effective.

Antispasmodics are the main medication for the treatment of hypertensive, hyperkinetic dysfunctions of the gallbladder and sphincter of Oddi during acute pain attacks and pain during the interictal period. Myotropic antispasmodics have a targeted effect on the smooth muscles of the entire biliary system. The results of numerous studies have shown that drotaverine (No-shpa) is the drug of choice from the group of myotropic antispasmodics, it allows to relieve pain, restore the patency of the cystic duct and the normal outflow of bile into the duodenum, and eliminate dyspeptic disorders. The mechanism of action is inhibition of phosphodiesterase, blocking Ca2+ channels and calmodulin, blocking Na+ channels, resulting in a decrease in the tone of the smooth muscles of the gallbladder and bile ducts. Dosage forms: for parenteral use - ampoules of 2 ml (40 mg) of drotaverine, for oral administration - 1 tablet of the drug No-Shpa (40 mg of drotaverine), 1 tablet of the drug No-Shpa forte (80 mg of drotaverine).

Advantages of the drug No-Shpa:

• Rapid absorption: the peak concentration of the drug in plasma occurs after 45-60 minutes, 50% absorption is achieved in 12 minutes, which characterizes drotaverine as a rapidly absorbed drug.
• High bioavailability: when taken orally it is 60%, after a single oral dose of 80 mg of drotaverine hydrochloride, the maximum concentration in plasma is achieved after 2 hours, penetrates well into the vascular wall, liver, wall of the gallbladder and bile ducts.
• The main route of metabolism is the oxidation of drotaverine to monophenolic compounds; the metabolites are quickly conjugated with glucuronic acid.
• Complete elimination: the half-life is 9-16 hours, about 60% of oral administration is excreted through the gastrointestinal tract and up to 25% in the urine.
• The presence of a dosage form of No-shpa for both oral and parenteral administration makes possible the widespread use of the drug in emergency situations.
• The drug No-shpa can be used during pregnancy (after carefully weighing the balance of benefits and risks).
• Quick onset of action, long-lasting effect: parenteral administration of drotaverine (No-Shpy) provides a quick (within 2-4 minutes) and pronounced antispasmodic effect, which is especially important for the relief of acute pain.
• The tablet form is also characterized by a rapid onset of action.
• High clinical effectiveness in small doses: 70%, 80% of patients experience relief of symptoms of spasm and pain within 30 minutes.
• There is no significant difference in the speed of achieving the antispasmodic effect between monotherapy with No-shpa and combination therapy.
• Time-tested safety, no serious side effects for a period of more than 50 years. The lack of anticholinergic activity affects the safety of drotaverine, expanding the range of people to whom it can be prescribed, in particular, in children, in elderly men with prostate pathology, with concomitant pathology and in combination with other drugs when taking two or more drugs simultaneously.

Thus, a review of the results of numerous clinical studies indicates that No-Spa is an effective drug for the rapid relief of spasms and pain in hypertensive, hyperkinetic forms of dyskinesia of the gallbladder and sphincter of Oddi.

Literature

1. Dadvani S. A., Vetshev P. S., Shulutko A. M. and others. Gallstone disease. M.: Vidar-M, 2000. 139 p.
2. Leischner W. Practical guide to biliary tract diseases. M.: GEOTAR-MED, 2001. 264 p.: ill.
3. Galperin E. I., Vetshev P. S. Guide to biliary tract surgery. 2nd ed. M.: Vidar-M, 2009. 568 p.
4. Ilchenko A. A. Diseases of the gallbladder and biliary tract: A guide for doctors. M.: Anacharsis. 2006. 448 p.: ill.
5. Ilchenko A. A. Cholelithiasis. M.: Anacharsis. 2004. 200 p.: ill.
6. Ivanchenkova R. A. Chronic diseases of the biliary tract. M.: Publishing house "Atmosphere", 2006. 416 pp.: ill.
7. Butov M. A., Shelukhina S. V., Ardatova V. B. On the issue of pharmacotherapy for biliary tract dysfunction / Abstracts of the V Congress of the Scientific Society of Gastroenterologists of Russia, February 3-6, 2005, Moscow. pp. 330-332.
8. Mathur S. K., Soonawalla Z. F., Shah S. R. et al. Role of biliary scintiscan in predicting the need for cholangiography // Br. J. Surg. 2000. No. 87 (2). P. 181-185.
9. Blasko G. Pharmacology, mechanism of action and clinical significance of a convenient antispasmodic agent: drotaverine // JAMA India - The physician’s update, 1998, v. 1 (No. 6), p. 63-70.
10. Functional diseases of the intestine and biliary tract: issues of classification and therapy // Gastroenterology. 2001, No. 5, p. 1-4.
11. Rational pharmacotherapy of diseases of the digestive system / Ed. V. T. Ivashkina. M.: Litterra, 2003, 1046 p.
12. Tomoskozi Z., Finance O., Aranyi P. Drotaverine interacts with L-type Ca2+ channel in pregnant rats uterine membranes // Eur. J. Pharmacol. 2002, v. 449, p. 55-60.
13. Malyarchuk V. I., Pautkin Yu. F., Plavunov N. F. Diseases of the major duodenal papilla. Monograph. M.: Cameron Publishing House, 2004. 168 pp.: ill.
14. Nazarenko P. M., Kanishchev Yu. V., Nazarenko D. P. Surgical and endoscopic methods of treatment of diseases of the large duodenal papilla of the duodenum and their clinical and anatomical rationale. Kursk, 2005. 143 p.

A. S. Vorotyntsev, Candidate of Medical Sciences, Associate Professor

GBOU VPO First Moscow State Medical University named after. I. M. Sechenov Ministry of Health and Social Development of Russia, Moscow

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Non-tumor diseases of the major duodenal papilla

Summary

Diseases of the major duodenal papilla (MDP) are currently not uncommon, but are extremely rarely diagnosed. The study of pathological processes localized in the organs of the pancreatobiliary zone has shown that BDS plays an important role in their origin. The occurrence of various diseases of the liver, bile ducts and pancreas is promoted not only by organic diseases of the obstructive system, but also by its functional disorders (sphincteral disorders). Late diagnosis leads to a large number of unsatisfactory treatment results for patients with cholelithiasis and pancreatitis.

BDS stenosis is a benign disease caused by inflammatory changes and cicatricial narrowing of the papilla, which cause obstruction of the bile and pancreatic ducts and associated pathological processes in the bile ducts and pancreas. In clinical practice, the term “stenosing duodenal papillitis” means: stenosis of the papilla of Vater, stenosis of the duodenal papilla, stenosis of the terminal part of the common bile duct, stenotic odditis, fibrosis of the sphincter of Oddi, stenosis of the hepatopancreatic ampulla, that is, narrowing of the ampulla of the BDS or the hepatopancreatic sphincter ampulla, as well as the adjacent section of the common bile duct. BDS is often called the Oddi space (zone). Narrowing of the space of Oddi occurs primarily due to inflammatory and fibrosing processes.

It is known that the structure of the BDS can be modified taking into account age characteristics. According to V.V. Pushkarsky (2004), with gallstone disease in old and senile age, the atrophic-sclerotic form of chronic papillitis predominates (up to 54% of cases), at the age of up to 60 years - hyperplastic (adenomatous, adenomyomatous) changes in the BDS.

The increased attention to acute and chronic inflammatory changes in the BDS is not accidental. According to A.I. Edemsky (2002), acute and chronic papillitis is observed in 100% of patients suffering from cholelithiasis, and in 89.6% of patients with recurrent pancreatitis. There are 3 forms of chronic pathological changes in the papilla: chronic adenomatous, adenomyomatous and atrophic-sclerotic chronic papillitis.

The BDS is located on the border of two (common bile duct and duodenum), and sometimes three (when the large pancreatic duct flows into the ampulla of the papilla) hollow systems. Pathogenic microflora, fluctuations in pressure and pH, stagnation in these two or three cavities contribute to the development of pathological changes in the BDS. Undoubtedly, the passage of dense structures, primarily the migration of stones along the common bile duct, also traumatizes it. The length of the BDS usually does not exceed 5-10 mm. Inside the papilla, in approximately 85% of cases, there is an extension of the common bile duct, which is designated as the ampulla of the papilla. The terminal part of the common bile duct adjacent to the papilla, with an average length of about 1 cm (0.6-3 cm), is located inside the wall of the duodenum and is called the intramural segment of the duct. Physiologically, this segment forms a single whole with the BDS. The cavity of the BDS, together with the terminal part of the common bile duct, is designated as the space of Oddi.

The locking apparatus of the BDS - the sphincter of Oddi - consists of: 1) the sphincter of the duodenal papilla itself, the so-called Westphal sphincter, which is a group of ring-shaped and longitudinal fibers reaching the apex of the duodenal papilla; when contracting, the Westphalian sphincter delimits the cavity of the papilla from the cavity of the duodenum; 2) the sphincter of the common bile duct - apparently the most powerful of this group of sphincters - the sphincter of Oddi, reaching a width of 8-12 mm; its proximal part often extends beyond the wall of the duodenum; during its contraction, it delimits the cavity of the common bile duct (and sometimes the pancreatic duct) from the cavity of the BDS; 3) the sphincter of the large pancreatic duct, usually poorly developed and sometimes completely absent. Stenosing duodenal papillitis affects not only the Westphal sphincter zone and the ampulla of the papilla, but also often the sphincter zone of the common bile duct, i.e. the entire Oddi zone. Thus, stenotic duodenal papillitis is, to some extent, a collective concept that covers at least two pathological processes: 1) stenosis of the duct in the area of ​​the ampulla of the ampulla; 2) stenosis of the terminal (mainly intramural) part of the common bile duct itself.

A significant part of long-term dyskinesias of the sphincter of Oddi essentially represents the initial stage of stenotic duodenal papillitis. With direct transduodenal endoscopy with thin (diameter 2.0-2.1 mm) probes, scar changes in the area of ​​the space of Oddi are detected in many such patients. The close anatomical and topographic relationship of the BDS with the biliary system and pancreas, as well as the dependence of the function of the BDS on the state of the organs of the biliopancreaticoduodenal zone and the pathological processes developing in them, significantly influence the state of the BDS. This leads to the fact that specific symptoms characteristic of the disease itself are quite difficult to identify. For this reason, the pathology of BDS is often not diagnosed. Nevertheless, the main symptom in which the doctor should think about a possible pathological process in the BDS is biliary or pancreatic hypertension (the occurrence of jaundice or the pain syndrome characteristic of pancreatitis).

BDS diseases can be divided into primary and secondary. Primary diseases include pathological processes localized in the BDS itself: inflammatory diseases (papillitis), benign and malignant tumors. Secondary diseases of the BDS include stones of the ampulla of the BDS, stenosis of the BDS (as a consequence of cholelithiasis), as well as compression of the BDS due to a pathological process localized in the head of the pancreas with pancreatitis or a tumor. Secondary diseases of the BDS include dysfunction of the sphincter apparatus of the BDS that occurs against the background of duodenal ulcer and duodenostasis. If the pathological process in the BDS develops against the background of diseases of the biliary system, the clinical picture is manifested by symptoms characteristic of cholelithiasis. In cases where the pathological process in the BDS is the cause of the development of inflammation of the pancreas, this is accompanied by clinical signs of pancreatitis. The appearance of jaundice may indicate that the pathological process is localized in the BDS. In this case, changes in the color of feces (gray, discolored) and urine (beer-colored urine) are noted. Violation of the outflow of bile into the duodenum may be accompanied by an increase in the patient’s body temperature, which is associated with the development of acute cholangitis.

Stenosing duodenal papillitis is a disease that is often asymptomatic and sometimes asymptomatic. Very often, the symptoms of narrowing of the BDS and the terminal part of the common bile duct are mistakenly associated with other pathological processes, primarily with manifestations of cholelithiasis itself (common bile duct stone, etc.). Perhaps, due to these circumstances and difficulties in recognition, a sometimes quite formidable disease did not attract the attention it deserved for a long time. Stenosing duodenal papillitis was described only at the end of the 19th century. as cicatricial stenosis of the papilla caused by an impacted stone. In 1926, D. Dell Vail and R. Donovan reported stenosing papillitis not associated with cholelithiasis, calling it scleroretractile odditis. As in Langebuch's time, stenotic duodenal papillitis continued to be considered a rare casuistic disease. Only in the 1950s and 60s did the situation change. The use of intravenous and operative cholangiography, manometry and radiometric studies allowed P. Mallet-Guy, J. Caroli, N. Hess and other researchers to identify the widespread prevalence of this disease, especially in cholelithiasis. Thus, W. Hess, out of 1220 cases of diseases of the gallbladder and biliary tract, noted stenosis of the BDS in 29%. With acalculous cholecystitis, stenotic duodenal papillitis was observed in 13%, with cholecystolithiasis - in 20%, with choledocholithiasis - in 50% of patients.

In the last two decades, since the widespread use of endoscopic examinations, and in particular endoscopic papillosphincterotomy, the incidence and clinical significance of this disease have become abundantly clear. There is a need to clearly distinguish between stenotic and non-stenotic (catarrhal) duodenal papillitis.

The development of stenotic duodenal papillitis is most often associated with cholelithiasis, primarily with choledocholithiasis. Injury to the papilla during the passage of the stone, an active infectious process in the folds and valve apparatus of the ampulla cause further development of fibrous tissue and stenosis of various parts of the ampulla of the ampulla or the part of the common bile duct immediately adjacent to it, i.e. Oddi zones.

With calculous cholecystitis and especially acalculous cholecystitis, the development of this disease is associated with a chronic infection that spreads through the lymphatic tract. P. Mallet-Guy suggested that in the pathogenesis of papillitis, an important role belongs to the following mechanisms: hypertension of the sphincter of Oddi, delayed evacuation of bile into the duodenum, activation of the infectious process in the area of ​​the urinary tract, and the development of inflammatory fibrosis. Inflammatory-fibrosing processes in the BDS often occur in patients with parafateral diverticulum, some forms of duodenitis, and duodenal ulcer. In case of peptic ulcer with localization of the ulcer in the duodenum and partly with duodenitis, the peptic factor plays a certain role in the development of stenotic duodenal papillitis. When alkalization processes in the vertical part of the duodenum were disrupted, which was confirmed by the method of multichannel pH-metry, traumatization of the BDS with hydrochloric acid was detected. It is the peptic component that in many cases is the cause of pain in people suffering from stenotic duodenal papillitis, which explains the analgesic effect of antacids and H2-blockers. The injured mucous membrane of the abdominal cavity, including the ampoule, is subsequently easily subject to bacterial invasion, and an infectious-inflammatory process develops.

As indicated, stenotic duodenal papillitis in many cases is a secondary process, in which cholelithiasis is considered as the root cause of the disease. Primary stenotic papillitis, in which there are no traditional causes (cholelithiasis, parafateral diverticula, etc.), appears to be less common. According to J. Caroli, this development of the disease is observed in 2-8% of patients. In recent years, the frequency of primary forms of stenotic duodenal papillitis has increased to 12-20%. The histological picture of the primary forms of the disease is identical to the secondary ones. The etiology of primary stenoses remains unclear. Based on morphological characteristics, three main forms of stenosis of the abdominal joint can be distinguished:

- inflammatory-sclerotic, characterized by varying degrees of fibrosis; in the early stages - hypertrophy and degenerative changes in the muscle fibers of the valve apparatus of the BDS with the presence of circle cell infiltrates, as well as fibrous tissue; in advanced cases, fibrous tissue is almost exclusively determined;

- fibrocystic form, in which, along with the phenomena of fibrosis, a large number of tiny cysts are detected, often representing sharply expanded pericanalicular glands, compressed by hypertrophied muscle fibers;

- adenomyomatous form, characterized by adenomatous hyperplasia of the pericanalicular glands, hypertrophy of smooth muscle fibers, proliferation of fibrous fibers (fibroadenomyomatosis), is often observed in older people.

Normally, the pressure in the common bile duct does not exceed 150 mm of water column. With stenotic duodenal papillitis, it increases to 180-220 mm water column. and more. With a rapid increase in pressure to 280-320 mm water column. An attack of hepatic colic may develop. In the duodenum, the pressure is normally up to 6-109 mm water column; under pathological conditions it can increase to 250-300 mm water column. In the pancreatic ducts under conditions of secretory rest, the pressure is 96-370 mm water column. At the height of secretin stimulation in the distal part of the main pancreatic duct, the pressure can reach 550-600 mm water column. In recent years, special catheters with a diameter of 1.7 mm (for example, Wilson-Cook, USA) are used to measure pressure, inserted into the duodenal papilla through an endoscope. The obtained data is recorded in the form of various curves.

The clinical picture of the disease is determined by the degree of narrowing of the bile and pancreatic ducts, biliary and pancreatic hypertension, infection, and secondary damage to the liver and pancreas. It is still unclear why in patients with almost identical anatomical changes in the BDS and the terminal part of the common bile duct, in some cases constant excruciating pain is observed every day, in others - only with errors in the diet, and in others - only minor episodic pain is observed and heartburn.

The most common symptom of stenotic duodenal papillitis is pain. Usually the pain is localized to the right and above the navel, sometimes in the epigastric region, especially in its right half. In a small proportion of patients, it migrates between the right hypochondrium and the epigastric region. Several types of pain can be distinguished: 1) duodenal type, when the patient is bothered by “hungry” or late pain, often quite long-lasting and monotonous; 2) sphincteric - short-term cramping, sometimes occurring with the first sips of food, especially when drinking cold fizzy drinks and fortified wines; 3) the choledocheal itself in the form of severe monotonous pain that appears 30-45 minutes after eating, especially heavy or rich in fat. In severe cases, the pain is persistent, long-lasting, and is often accompanied by nausea and vomiting. The most pronounced pain syndrome is more often observed in patients with a relatively insignificant expansion of the common bile duct to 10-11 mm. In rare cases of sudden dilatation of the bile duct (up to 20 mm or more), the pain syndrome is much less pronounced. It has already been indicated that pain occurs and intensifies after a rich, fatty meal. Refractory fats (pork, lamb, beef lard, sturgeon fat) are dangerous in this regard. The combination of fat and dough is especially dangerous - pies, goose pies, pancakes with sour cream; It is they who often provoke a sharp exacerbation of the disease. Cold fizzy drinks are intolerable to most patients. In some patients, warm bread causes increased pain.

More than half of the patients experience various manifestations of dyspeptic syndrome: nausea, vomiting, bad breath and heartburn. In some patients, frequent vomiting is the most painful manifestation of the disease. After endoscopic papillosphincterotomy, the previously observed vomiting, as a rule, stops, while pain in the upper abdomen only decreases. Vomiting is considered a characteristic symptom of stenotic duodenal papillitis. In contrast to the latter, vomiting is very rarely observed in uncomplicated forms of BDS cancer. A common concomitant disease, cholangitis, is associated with complaints such as chills, malaise, and low-grade fever. Stunning chills with paroxysmal rise in temperature are less common than in persons with a common bile duct stone. Mild short-term jaundice is observed in a third of patients. Bright, long-term jaundice in the absence of concomitant diseases (common bile duct stone, parafateral diverticulum, etc.) is rare. Progressive weight loss is also rare. A slight weight loss of 2-3 kg is often noted. Palpation of the epigastric region in most patients gives an uncertain result. Only in 40-45% of patients it is possible to identify an area of ​​local (usually low-intensity) pain 4-6 cm above the navel and 2-5 cm to the right of the midline, approximately corresponding to the Shoffar area. Peripheral blood in most patients is not changed; only 20-30%, during exacerbation of the disease, experience slight leukocytosis and, even more rarely, a moderate increase in erythrocyte sedimentation rate (ESR).

The addition of cholangitis, especially purulent one, entails the appearance of leukocytosis with a band shift and a significant increase in ESR. Similar changes are observed with the development of acute pancreatitis in patients with stenosing duodenal papillitis. Delayed movement of bile through the common bile duct and the major duodenal papilla is an important diagnostic sign of the disease. Two methods help in this regard. In case of short-term (0.5-3 days) disturbances in the outflow of bile, occurring after the consumption of significant doses of alcohol or errors in the diet and, probably, associated with increased edema in the area of ​​the ampulla of the papilla, a short-term but significant (5-5) 20 times) increase in the activity of glutamate dehydrogenase, aminotransferases and serum amylase. These changes are recorded especially clearly in the first 4-8 hours of increased pain. Such exacerbations of the disease often occur in the afternoon or at night. A simultaneous moderate increase in serum bilirubin levels with such short-term disturbances in the outflow of bile is rarely observed. With a single emergency blood draw performed in the first hours of a sharp increase in abdominal pain, an increase in enzyme activity is detected in 50-60% of those examined. In a double study of this type, severe hyperenzymemia is detected in 70-75% of those examined.

For long-term stable disorders of bile outflow, radionuclide methods are quite effective. When performing isotope hepatography in 50-60% of patients, a slowdown in the entry of radionuclide into the duodenum is detected. When conducting cholescintigraphy using acetic acid derivatives (drugs HIDA, IDA, etc.), a moderate slowdown in the entry of radionuclide into the duodenum is observed in 65-70% of those examined; in 7-10%, a paradoxical phenomenon is detected - accelerated entry of small portions of the drug into the intestine, apparently associated with the weakness of the sphincter system of the abdominal joint. In general, a repeated emergency study of enzyme activity at the onset of a sharp increase in pain and planned cholescintigraphy can reveal in 80-90% of patients with stenosing duodenal papillitis symptoms of delayed flow of bile into the duodenum (in essence, symptoms of acute and chronic biliary hypertension).

An important place in the diagnosis of the disease is occupied by the endoscopic method and combined endoscopic-radiological (x-ray) research methods. With catarrhal and stenotic papillitis, the papilla is often enlarged, reaching 1.5 cm. The mucous membrane is hyperemic and edematous. An inflammatory whitish coating is often visible at the top of the papilla. A characteristic sign of stenosing papillitis is flattening of the papilla. A flattened, wrinkled papilla is characteristic of a long-term process.

Intravenous cholegraphy data often play a major role in distinguishing between catarrhal and stenotic papillitis. With a stenotic process in 50-60% of patients, as a rule, a moderate (10-12 mm) expansion of the common bile duct is determined. The contrast agent is retained in the common bile duct. In some patients, it is also possible to detect a funnel-shaped narrowing of the terminal part of the common bile duct. Sometimes this narrowing looks peculiar - in the form of a writing pen, an inverted meniscus, etc. Occasionally, an expansion of the ampulla of the BDS is detected. Important examination results can be obtained during laparotomy. Operative cholangiography, often performed through the stump of the cystic duct, brings results close to those of endoscopic retrograde cholangiopancreatography (ERCP). It is often performed in two steps. First, 1/3 of the contrast volume is injected and an image is taken. It usually shows the stones of the common bile duct quite clearly. Then a second, larger portion of contrast is injected. The image shows tight filling of the common bile duct, its narrowing and delayed emptying are visible. Small stones in the duct are often invisible when filled tightly. Manometric examination of the common bile duct is mainly performed during surgery, although in recent years special probes adapted for manometry have been manufactured that are inserted transduodenally.

Bougienage of the OBD for diagnostic purposes during surgery finds some application. Normally, a probe with a diameter of 3 mm passes relatively freely through the Oddi zone into the duodenum. The possibility of inserting a probe of a smaller diameter (2 mm or only 1 mm) indicates stenosing duodenal papillitis. The bougienage procedure itself is quite traumatic. Sometimes it causes severe injury to the area of ​​the duodenal papilla. Not all surgeons are willing to undertake this study.

ERCP plays an important role in recognizing stenotic duodenal papillitis. When performing catheterization of the BDS, difficulties often arise. Some of them, when a catheter is inserted into the common bile duct, may indicate stenosing duodenal papillitis. Moreover, when inserting a catheter, the endoscopist sometimes quite accurately determines the length of the narrowing area. Varying degrees of narrowing of the space of Oddi are observed in 70-90% of patients. The delay in emptying of contrast plays a certain diagnostic role. If the delay is more than 45 minutes, we can talk about stenosis or prolonged spasm of the Oddi area.

Ultrasound plays a relatively minor role in recognizing stenosis of the abdominal joint. Since the BDS is located in the wall of the duodenum, diagnosing changes in this organ using the ultrasound method is impossible. Ultrasound has little ability to visualize the terminal portion of the common bile duct, much less the BDS. The ability to determine the diameter of the common bile duct often seems limited. The main value of ultrasound is related to clarifying the condition of the head of the pancreas and gallbladder. Accurate data on the condition of these organs is very important when making a diagnosis of stenotic duodenal papillitis. CT results can be evaluated in approximately the same way as ultrasound.

Differential diagnosis. First of all, the issue of the possible presence of stones in the common bile duct should be resolved. The results of ultrasound and intravenous cholegraphy when identifying stones in large bile ducts are often not reliable enough, so in such a situation, ERCP is necessary. Occasionally, in cases of persistent jaundice, it is necessary to resort to percutaneous cholangiography. Among other diseases of the common bile duct and adjacent organs with relatively similar symptoms, one should keep in mind: 1) parafateral diverticulum; 2) indurative pancreatitis; 3) proximally located narrowing of the common bile duct, primarily in the area of ​​confluence of the cystic duct; 4) cancer of the head of the pancreas; 5) cancer of the common bile duct; 6) primary sclerosing cholangitis.

Both primary and secondary sclerosing cholangitis are usually characterized by the fact that the extrahepatic and less intrahepatic ducts are affected, which is recorded by ERCP in the form of alternating narrowings and dilations of the common bile duct. In doubtful cases (and this is not so rare), ERCP has to be repeated, and the second targeted study, as a rule, gives a definite, almost unambiguous result. As you can see, ERCP in combination with ultrasound and CT plays a major role in differential diagnosis.

Clinical significance of stenotic duodenal papillitis. In most cases, this disease is, as it were, in the shadow of another pathology, which is considered as the main one. First of all, such a basic disease is choledocholithiasis, somewhat less often - cholecystolithiasis. It is not so rare that stenotic duodenal papillitis appears in the shadow of chronic acalculous cholecystitis and parafateral diverticulum. To a certain extent, these four different diseases are united by the low effectiveness of treatment when patients also have papillitis. Removal of stones from the gallbladder and common bile duct, rehabilitation of acalculous cholecystitis and parafateral diverticulum are often ineffective, i.e. do not reduce the manifestations of clinical symptoms when papillitis is ignored therapeutically. In more than half of patients with postcholecystectomy syndrome, symptoms are mainly or largely associated with stenotic duodenal papillitis, which was either not recognized or was not eliminated during the period of cholecystectomy. Of the two diseases that the patient suffered from, cholecystectomy resolved the issue with only one of them. It is not surprising that after cholecystectomy, papillitis is often more severe than before the operation. Before a planned cholecystectomy, the danger of viewing papillitis and choledocholithiasis makes it necessary to perform duodenoscopy and intravenous cholegraphy.

Treatment. Patients with the most severe forms of stenotic duodenal papillitis, occurring with persistent pain, vomiting, repeated jaundice, and weight loss, are subject to endoscopic or surgical treatment. As a rule, they perform endoscopic papillosphincterotomy. Only in cases where the stenosis extends beyond the space of Oddi, transduodenal papillosphincterotomy with plasty is performed.

For milder forms, conservative therapy is prescribed, which includes diet No. 5, antacid therapy, and for particularly persistent pain, H2 blockers are used; anticholinergic therapy - atropine, platifillin, metacin, aeron, gastrocepin; antibacterial therapy.

Endoscopic papillosphincterotomy is especially indicated for dilation of the common bile duct. Its effectiveness varies. More often the pain syndrome decreases. Vomiting usually stops. Jaundice does not recur. In patients with a preserved gallbladder, acute cholecystitis develops relatively often (up to 10%) immediately after the intervention and during the first month. This pattern seems to emphasize the connection between pathological processes in the area of ​​the obstructive system and the gallbladder.

During the period of remission, patients with papillitis are recommended a special diet, which can be regarded as maintenance therapy. Patients are also recommended to walk at least 5-6 km daily, do morning exercises without jumping and do abdominal exercises. Swimming is recommended. Nutrition should not be excessive, you should monitor the stability of body weight. Meals should be frequent: at least 4 times a day. It is advisable to enrich the diet with vegetables and vegetable oil. Refractory fats, cold fizzy drinks, hot seasonings, and fried foods are prohibited. Large meals at night are especially undesirable. If there is a slight increase in dull pain in the right hypochondrium, nausea, or heartburn, a course of treatment with choleretic drugs is recommended.

Thus, the pathology of BDS often leads to severe complications, often requiring emergency surgical treatment. At the same time, qualified morphological diagnosis of the pathological process of a given anatomical formation is extremely important, which subsequently plays a leading role in the choice of treatment tactics and the extent of surgical intervention.