Due to the gallbladder temperature 37. Is there a temperature in cholecystitis? During chronic cholecystitis

Cholecystitis is an inflammatory disease that occurs in the gallbladder and is accompanied by severe symptoms. Cholecystitis, the symptoms of which occur, as, in fact, this disease itself, in about 20% of adults, can occur in an acute or chronic form.

general description

Cholecystitis, as we have already noted, is a fairly common disease, which, in particular, is explained by a number of factors that provoke its development and directly by their prevalence. Such factors include a sedentary lifestyle and dietary habits (foods saturated with animal fats, such as butter, eggs, meat, etc.), endocrine disorders (diabetes, overweight), etc. It is noteworthy that women are prone to cholecystitis several times more often - this is due to the use of oral contraceptives, as well as pregnancy.

Each of the listed states represents one of the phases of the whole pathological process. So, the motility of the gallbladder is initially disturbed, which manifests itself in the form of dyskinesia, after which the inflammatory process itself is connected, but already in the form of acalculous cholecystitis, and after that, over time, this form of cholecystitis is transformed into cholelithiasis (gallstone disease).

Additional factors include the following:

• . The disease is noted in any course of chronic cholecystitis, is the main cause that provokes stagnation of bile and a violation of its outflow.
• Reflux pancreatic. In this case, the contents of the duodenum enters directly into the bile ducts. The effect exerted in this case by active enzymes in combination with pancreatic juice causes, in turn, damage in the area of ​​the walls of the gallbladder. Pancreatic reflux usually occurs in diseases of the duodenum, as well as in diseases of the pancreas.
• congenital anomalies. In this case, we are talking about anomalies associated with the development of the gallbladder.
• Disorders associated with the blood supply to the gallbladder. Diseases of the type, and others lead to such complications. Their course is accompanied by narrowing of the vascular lumen.
• Dyscholia. This disease is associated with a violation of the composition of bile, as a result of which the wall of the gallbladder is also damaged. The peculiarities of nutrition lead to a similar result, in which it is characterized by saturation with fats and general monotony.
• Immunological reactions, allergic reactions. Against their background, changes of the corresponding type occur, also concerning the wall of the gallbladder.
• Endocrine disorders. Here, as we noted above, we are talking about the use of oral contraceptives, as well as irregularities in the menstrual cycle, overweight and pregnancy.
• Heredity.

It is the impact of additional factors that we have considered that ensures the formation of appropriate conditions against which inflammation subsequently develops, and infection also occurs.

According to the nature of the course, cholecystitis can be acute or chronic, according to the characteristics of the course - catarrhal, phlegmonous and gangrenous.

Acute cholecystitis: symptoms

About 95% of patients with the disease in this form are also sick with cholelithiasis, in which stones appear in the gallbladder. When a stone enters the cystic duct, that is, into the channel that ensures the flow of bile from the gallbladder, it gets stuck there, which, in turn, leads to the accumulation of bile in the gallbladder. Against this background, an infection develops, due to which the walls of the gallbladder become inflamed, and, accordingly, acute cholecystitis develops.

Due to the stagnation of bile that is relevant in this case, enzymes are released, due to which the inflammation intensifies. The affected mucosa of the bladder releases a larger volume of fluid than it can absorb against the background of the processes under consideration. For this reason, the fluid accumulates, contributing in parallel to the stretching of the walls of the gallbladder and the intensification of the inflammatory process.

Sometimes acute cholecystitis causes the gallbladder to die and rupture.

After the end of the episode with acute inflammation, the organ affected by it becomes dense and compressed, as a result of which its ability to concentrate bile is lost. Such a course, in turn, becomes the basis for the development of chronic cholecystitis, which we will also consider below. Now let's dwell on the symptoms that accompany acute cholecystitis. Before that, I would also like to note that cholecystitis can be acalculous, that is, its course is not accompanied by the appearance of stones. In cases of acute cholecystitis, this form of the disease accounts for about 10%.

Given the predominant appearance of acute cholecystitis in those patients who have gallstones, the symptoms of this disease often manifest themselves in combination with the symptoms noted in cholelithiasis. For example, in patients with acute cholecystitis, as it turns out, symptoms of hepatic colic were previously manifested.

So, the main symptom that accompanies a disease such as acute cholecystitis is the appearance. Such pain is similar to the pain that occurs with biliary colic, both in terms of strength of manifestation and in terms of localization, however, with cholecystitis it lasts much longer (up to 6 hours or more), respectively, it also has a stronger manifestation. In addition, an attack of the disease also manifests itself in combination with nausea and vomiting.

In the period of several hours from the onset of the onset of the disease, patients have Murphy's symptom, which consists in increased pain with a deep breath at the time of probing the area of ​​the gallbladder, in addition, there is a characteristic muscle tension in the region of the right side of the upper abdomen. The temperature in cholecystitis generally rises slightly, but, as a rule, its change is noted in most patients.

Older people often experience the first, and often the only symptoms of this disease in the form of lack of appetite and general malaise, fever, weakness and vomiting.

Acute acalculous cholecystitis is characterized by symptoms similar to the course of the disease resulting from the appearance of gallstones. In some cases, fever and bloating are the only manifestations of the disease in question.

It should be noted that the lack of treatment can lead to perforation of the gallbladder, followed by shock and. Such development of cholecystitis determines rather high mortality rates, which reaches about 65%.

If, in general, the treatment of cholecystitis is carried out in the right way, then the prognosis for it is determined as favorable. The symptomatology characteristic of the course of acute cholecystitis weakens after 2-3 days, completely disappearing within a period of one week (about 80% of cases).

Acute cholecystitis and pregnancy

Acute cholecystitis develops during pregnancy much more often than in other cases, which is explained by the compression of the entire digestive tract by the uterus. Accordingly, within the area of ​​interest to us, for this reason, stagnation of bile in combination with the formation of stones is noted, all this, as we noted above, leads to the development of cholecystitis.

The course of acute cholecystitis during pregnancy is associated with certain risks. First of all, pregnancy severely limits the possibility of using antibiotics, which are the main solution in the treatment of cholecystitis. Naturally, surgery to remove an inflamed gallbladder is an extremely undesirable action.

Catarrhal cholecystitis: symptoms

Catarrhal cholecystitis is characterized by the appearance of constant and rather intense pain, concentrated in the region of the right hypochondrium and epigastrium. There is a spread of pain to the right shoulder blade, lower back, neck and shoulder girdle.

The onset of the disease to this form can manifest itself in the form of paroxysmal pain resulting from increased contraction of the walls of the affected organ. Vomiting is also often noted, after which patients do not experience relief. Initially, vomit includes only gastric contents, after - and duodenal.

The temperature rises to subfebrile indicators, is characterized by moderate manifestations (of the order of about 100 beats / min.), In some cases, pressure may increase. The tongue of patients becomes wet, a whitish coating appears on it. The act of breathing is disturbed, the stomach takes part in it.

Palpation of the abdomen reveals a sharp pain in the right hypochondrium, especially in the gallbladder. Ortner and Murphy syndromes also appear, which mean the appearance of pain when tapping along the right costal arch with the edge of the palm and increased pain during probing the gallbladder area with a deep breath. There is also pain in the area above the right clavicle (Mussi-Georgievsky syndrome).

Phlegmonous cholecystitis: symptoms

This form of the disease is somewhat more severe than in the case of the previous form. So, the symptoms of phlegmonous cholecystitis are the appearance of severe pain in the right hypochondrium, severe weakness, high temperature (up to 39 ° C), loss of appetite, chills. Blood tests determine.

The emerging pain is more intense than in the previously considered form of cholecystitis, its intensification is noted when coughing and breathing, as well as when changing the position of the body.

Nausea occurs much more often, vomiting is repeated. The general condition is also deteriorating. Again, when probing, there is a pronounced soreness. The previously discussed symptoms of Murphy, Ortner and Mussi-Georgievsky are also relevant.

The gallbladder increases in size, during examination at this stage there is a thickening of its wall, the presence of purulent exudate in the lumen. In some cases, the wall of the gallbladder may be characterized by the appearance of abscesses on it.

Gangrenous cholecystitis: symptoms

This form of cholecystitis, as a rule, develops against the background of the previous form, that is, the phlegmonous form. In this case, the impossibility of an exhausted organism to fight microorganisms, the impact of which accompanies the course of the pathological process, is determined.

Gangrenous cholecystitis is accompanied by the severity of symptoms of intoxication, which, again, manifest themselves in the form of general weakness, temperature, and sweating. There are also manifestations characteristic of general or local peritonitis (its purulent form).

As a rule, gangrenous cholecystitis appears in the elderly, which is explained by the deterioration of the protective properties inherent in the body, as well as disorders noted in the features of the blood supply to the walls of the gallbladder that occur against the background of atherosclerosis.

With the transition of the inflammatory process to the considered form of the course of the disease, abdominal pain may decrease somewhat, which causes an erroneous assumption regarding the improvement of one's own condition (the so-called imaginary well-being). In fact, the weakening of this symptom is the result of the death of the nerve endings of the affected organ.

After some time, after a period of imaginary well-being, they become aggravated again, in addition to this, symptoms of widespread peritonitis also appear. This condition is accompanied by an increase in the frequency of contractions of the heart (about 120 beats / min.), An increase in temperature.

Inspection determines the dryness of the tongue. Due to the relevance of intestinal paresis, bloating occurs, its right sections do not participate in breathing. In general, breathing is characterized by rapidity and superficiality.

Probing reveals the severity of protective muscle tension in the region of the anterior abdominal wall.

Chronic cholecystitis: symptoms

Predominantly chronic cholecystitis develops as an independent disease, which is especially important in the presence of predisposing factors. Somewhat less often, chronic cholecystitis develops against the background of the preliminary manifestation of episodes of this disease in an acute form.

The course of chronic cholecystitis is characterized by its own duration, that is, it can last for many years. High-quality, timely and effective treatment allows to achieve remission of the disease, in which, accordingly, the disease “fades out” for a long time. If there is no treatment, then there is a gradual wrinkling of the organ affected by the disease in question, as a result of which it completely loses its characteristic functions. Now let's dwell on the symptoms that accompany chronic cholecystitis.

• Pain in the right hypochondrium (abdominal pain). The chronic form of the course of cholecystitis is accompanied by aching and dull pain, the duration of which can be either several hours or several days in a row. A characteristic feature of such pain in chronic cholecystitis is its appearance or intensification as a result of the consumption of fried or fatty foods. The chronic form of the disease and pain in it, in particular, is characterized by its spread upward, that is, to the neck and to the right shoulder. Also, pain can be given to the heart, to the lower back.
• Vomit. This symptom of chronic cholecystitis is not mandatory in the manifestation, but it is also not necessary to exclude it. As a rule, vomiting appears similar to pain, namely, when eating foods that are excluded by the appropriate diet for cholecystitis. The presence of bile in the vomit is noted.
• "Salt Syndrome". It appears as a result of a long course of cholecystitis. Its main symptom is the appearance of intense and burning pain, concentrated in the navel with irradiation (spread) to the back.
• Bitterness in the mouth, belching bitter .
• Skin itching . It occurs as a result of an actual violation of bile secretion, is a kind of result of irritation to which skin receptors are exposed due to bile acids that accumulate in the blood.
• . It has a short-term character, appears, again, due to disorders associated with the outflow of bile.
• Temperature, chills . These manifestations are relevant in exacerbation of the chronic form of cholecystitis.
• Sweating, weakness .
• Mood instability .
• Headache .
• Sleep disorders .

In patients with allergies, the exacerbation of the disease in question is accompanied by the appearance of allergic reactions (,).

Women may experience premenstrual tension. So, for a period of 2 to 10 days before the onset of menstruation, they may experience mood instability, headaches, pastosity (swelling) of the face, legs, hands. At the same time, symptoms appear that indicate an exacerbation of chronic cholecystitis.

The following are used as instrumental methods for diagnosing cholecystitis:

• duodenal sounding (multifractional).
• x-ray examination;
• esophagogastroduodenoscopy (abbr. EGDS);
• CT, MRI (for complicated cases of diagnosis).

Treatment of cholecystitis

If the clinical manifestations and the results of laboratory tests indicating the presence of inflammation are relevant, the doctor prescribes specific antibiotic therapy. The selection of antibiotics is made only by a doctor based on the ability of the selected drug to concentrate in bile.

In addition, the treatment is also focused on the elimination of concomitant symptoms, that is, the normalization of the functions characteristic of the biliary tract and the elimination of pain that occurs with cholecystitis.

In addition to specific therapeutic measures, a diet is also being developed. A certain effect is given by the treatment of cholecystitis with folk remedies.

Diagnosis of cholecystitis is made at the appointment of a general practitioner and a gastroenterologist, additional indications may include a consultation with a surgeon, cardiologist, gynecologist and psychotherapist.

Acute cholecystitis is an inflammation of the gallbladder, characterized by a sudden onset, rapid increase and severity of symptoms. This is a disease that occurs in a patient for the first time and, with adequate treatment, ends in recovery. In the same case, if the manifestations of acute cholecystitis are repeated repeatedly, this is regarded as an exacerbation of chronic cholecystitis, which is characterized by an undulating course.

In women, acute cholecystitis is diagnosed more often than in men. With age, the incidence increases. In this regard, experts suggest that hormonal changes may influence the development of acute cholecystitis. At increased risk are people who are obese, taking hormonal drugs and pregnant women.

Acute cholecystitis is an acute, rapidly developing inflammation of the gallbladder.

Causes and risk factors

The main cause of acute cholecystitis is a violation of the outflow of bile from the gallbladder and its infection with pathogenic microbial flora (E. coli, salmonella, streptococci, staphylococci). With preserved drainage function, i.e., with undisturbed outflow, infection of bile does not lead to the development of the disease.

Factors that increase the risk of developing acute cholecystitis include:

• age over 40;
• sedentary lifestyle;
• malnutrition with a high content of fatty foods in the diet;
• female;
• European race;
• pregnancy;
• hormonal contraception;
• obesity;
• prolonged fasting;
• salmonellosis;
• sickle cell anemia;
• sepsis;
• violation of the rheological properties of blood.

Forms of the disease

Depending on what caused the blockage of the bile duct, calculous (stone) and non-calculous (stoneless) acute cholecystitis are distinguished.

According to the degree of morphological changes in the gallbladder, cholecystitis is:

• catarrhal - the inflammatory process is limited to the mucosa and submucosa of the gallbladder;
• phlegmonous - purulent inflammation, in which infiltration of all layers of the walls of the gallbladder occurs. In the absence of treatment, the mucous membrane ulcerates, and the inflammatory exudate penetrates into the perivesical space;
• gangrenous - necrosis of the gallbladder wall occurs (partial or total);
• gangrenous-perforative - perforation of the gallbladder wall in the area of ​​necrosis with the release of bile into the abdominal cavity, which leads to the development of peritonitis;
• empyema - purulent inflammation of the contents of the gallbladder.

In women, acute cholecystitis is diagnosed more often than in men. With age, the incidence increases.

Symptoms of acute cholecystitis

The disease begins with a sudden pain attack (biliary, or hepatic colic). The pain is localized in the region of the right hypochondrium or epigastrium, may radiate to the right half of the neck, the right supraclavicular region, to the region of the lower angle of the right scapula. A pain attack usually develops after severe emotional stress, eating fatty, spicy foods and/or alcohol. The pain is accompanied by nausea and vomiting, fever. Approximately 20% of patients develop obstructive jaundice due to blockage of the bile duct by edema or calculus.

Specific symptoms of acute cholecystitis:

• Murphy's symptom - the patient involuntarily holds his breath at the moment of pressure in the right hypochondrium;
• Ortner's symptom - tapping along the edge of the right lower costal arch is accompanied by increased pain;
• Kera's symptom - increased pain on inspiration during palpation in the right hypochondrium;
• phrenicus-symptom (symptom of de Mussy - Georgievsky) - pressing with a finger between the legs of the sternocleidomastoid muscle on the right is accompanied by painful sensations;
• percussion of the anterior abdominal wall reveals tympanitis, which is explained by the development of reflex intestinal paresis.

A sign of the development of peritonitis, i.e. involvement in the inflammatory process of the peritoneum, is a positive symptom of Shchetkin - Blumberg - a sharp pain when pulling back the hand pressing on the stomach.

Diagnosis of acute cholecystitis

The diagnosis of acute cholecystitis is made on the basis of a characteristic clinical picture, confirmed by laboratory and instrumental examination data:

• complete blood count (leukocytosis, shift of the leukocyte formula to the left, acceleration of ESR);
• biochemical blood test (increased activity of liver enzymes, increased alkaline phosphatase, bilirubin);
• urinalysis (appearance of bilirubin in obstructive jaundice);
• ultrasound scanning of the gallbladder (presence of stones, thickening of the walls, infiltrate of the perivesical space);
• radioisotope scanning of the gallbladder;
• chest x-ray and electrocardiography for the purpose of differential diagnosis.

At an increased risk of acute cholecystitis are people who are obese, taking hormonal drugs and pregnant women.

X-ray of the abdominal cavity with this disease is not very informative, because in 90% of cases, gallbladder stones are X-ray negative.

Differential diagnosis of acute cholecystitis with the following diseases is necessary:

Treatment of acute cholecystitis is carried out in a surgical department of a hospital, strict bed rest is indicated. During the first 24-48 hours, gastric contents are evacuated through a nasogastric tube. The liquid during this period is administered intravenously.

After the signs of acute inflammation subside, the probe is removed and the patient is prescribed a water-tea break for several days, and then diet No. 5a according to Pevzner. 3-4 weeks after the subsidence of all symptoms of the disease, the diet expands, and the patient is transferred to diet No. 5. Diet for acute cholecystitis is one of the main methods of treatment. Frequent meals in small portions contribute to a good outflow of bile. To reduce the load on the liver and biliary system in the diet, it is reasonable to reduce the content of animal fats, seasonings, and essential oils.

Western experts have a different approach to organizing a diet for acute cholecystitis. They also limit the content of fat in the diet, but recommend eating no more than 2-3 times a day with a mandatory 12-16-hour break at night.

Conservative treatment of acute cholecystitis includes the implementation of pararenal novocaine blockade according to Vishnevsky in order to relieve acute pain, as well as the appointment of antispasmodic and antibacterial drugs.

After relief of the symptoms of acute cholecystitis in the presence of stones in the gallbladder, lithotripsy is recommended, i.e., the dissolution of stones (drugs of ursodeoxycholic and chenodeoxycholic acids).

Surgical treatment of acute cholecystitis is carried out according to the following indications:

• emergency - the development of complications (peritonitis, etc.);
• urgent - ineffectiveness of conservative therapy carried out within 1-2 days.

The essence of the operation is to remove the gallbladder (cholecystectomy). It is performed by both traditional open and laparoscopic methods.

Possible consequences and complications

Acute cholecystitis is a dangerous disease that, in the absence of qualified assistance, can lead to the development of the following complications:

• empyema (acute purulent inflammation) of the gallbladder;
• perforation of the gallbladder wall with the formation of a perivesical abscess or peritonitis;
• gallstone obstruction of the intestine (overlapping of the lumen of the small intestine with a significant calculus migrating from the gallbladder);
• emphysematous cholecystitis (develops as a result of infection of bile with gas-producing bacteria - clostridia).

After removal of the gallbladder, a small proportion of patients develop postcholecystectomy syndrome, which is manifested by frequent loose stools. In this case, following a diet helps to quickly achieve normalization. Only in 1% of operated patients, diarrhea is persistent and requires medical treatment.

Forecast

The prognosis for uncomplicated forms of acute cholecystitis, provided timely medical care is provided, is generally favorable. Acute non-calculous cholecystitis usually ends in complete recovery and only in a small percentage of cases becomes chronic, the likelihood of chronicity of acute calculous cholecystitis is much higher.

The prognosis deteriorates sharply with the development of complications (peritonitis, perivesical abscess, empyema). The probability of death in this case is, according to various sources, 25-50%.

Prevention

Prevention of acute cholecystitis includes the following measures:

• compliance with the rules of a healthy diet (restriction of fats and spices, eating in small portions, dinner no later than 2-3 hours before bedtime);
• refusal to abuse alcoholic beverages;
• sufficient physical activity during the day;
• compliance with the water regime (during the day you should drink at least 1.5 liters of liquid);
• avoidance of psycho-emotional stress and physical overload;
• normalization of body weight;
• timely diagnosis and treatment of helminthic invasions (giardiasis, ascariasis).

Video from YouTube on the topic of the article:

- this is a temperature at the level of 37-37.5 ° C for a long time. At the same time, a person may completely lack symptoms of any disease, and malaise may appear. We are talking about subfebrile temperature not when isolated cases of fever are recorded: this may be due to the individual characteristics of the body and the factors described above, but if subfebrile temperature is recorded in the temperature curve with measurements taken over many days in a row.

A true temperature increase is considered to be a temperature above 38.3 degrees.. Such a temperature is accompanied by very specific symptoms that correspond to a very specific disease. But prolonged low-grade fever is often the only sign to find out the cause of which you will have to run around the doctors.

The normal temperature of the human body is recognized as a temperature of 36.6 ° C, although for many, 37 ° C is fixed as a normal temperature. It is this temperature that is observed in a healthy organism: child or adult, male or female - it does not matter. This is not a stable static unchanging temperature, during the day it fluctuates in both directions depending on overheating, hypothermia, stress, time of day and biological rhythms. Therefore, temperatures from 35.5 to 37.4 ° C are considered the normal range.

Body temperature is regulated by the endocrine glands - the thyroid gland and the hypothalamus.. The receptors of the nerve cells of the hypothalamus respond to body temperature by changing the secretion of TSH, which regulates the activity of the thyroid gland. Thyroid hormones T3 and T4 regulate the intensity of metabolism, on which the temperature depends. In women, the hormone estradiol is involved in temperature regulation. With an increase in its level, the basal temperature decreases - this process depends on the menstrual cycle. In women, body temperature changes by 0.3-0.5 °C during the menstrual cycle. The highest rates of up to 38 degrees are observed between 15 and 25 days of a standard menstrual cycle of 28 days.

In addition to the hormonal background, temperature indicators are slightly affected by:

• physical exercise;
• food intake;
• in children: strong prolonged crying and active games;
• time of day: in the morning the temperature is usually lower (the lowest temperature is observed between 4-6 am), and in the evening it reaches a maximum (from 18 to 24 am - the period of max temperature);
• the temperature drops in the elderly.

Physiological fluctuations in thermometry during the day within 0.5-1 degrees are considered the norm.

Subfebrile condition does not belong to the normal state of the body and therefore the main question that is posed to the doctor is to identify the causes of the pathology. If the patient has recently been ill and treated for a long time, it is believed that the increase in temperature is associated with the recovery process. If there was nothing like that, then you have to look for the dysfunction that caused this symptom. For a more accurate detection of pathology, it is recommended to draw up a temperature curve, an analysis of well-being, and laboratory diagnostics.

Diseases that are characterized by subfebrile condition

Infectious causes of diseases

Infections are the most common cause of subfebrile condition. With the prolonged existence of the disease, the symptoms are usually erased and only subfebrile condition remains. The main causes of infectious subfebrile condition are:

• ENT diseases - sinusitis, tonsillitis, otitis media, pharyngitis, etc.
• Dental diseases and carious teeth including.
• Gastrointestinal diseases - gastritis, pancreatitis, colitis, cholecystitis, etc.
• Diseases of the urinary tract - pyelonephritis, cystitis, urethritis, etc.
• Diseases of the genital organs - inflammation of the appendages and prostatitis.
• Abscesses from injections.
• Non-healing ulcers in diabetic patients.

Autoimmune diseases

In autoimmune diseases, the body's immune system begins to attack its own cells, which causes chronic inflammation with periods of exacerbation. For this reason, body temperature also changes. The most common autoimmune pathologies:

• rheumatoid arthritis;
• systemic lupus erythematosus;
• Hashimoto's thyroiditis;
• Crohn's disease;
• diffuse toxic goiter.

To detect autoimmune diseases, tests for ESR, C-reactive protein, rheumatoid factor, and some other examinations are prescribed.

Oncological diseases

In malignant tumors, subfebrile condition can be an early manifestation of the disease, 6 to 8 months ahead of its symptoms. In the development of subfebrile condition, the formation of immune complexes that trigger an immune response plays a role. However, an early rise in temperature is associated with the onset of production of a specific protein by the tumor tissue. This protein is found in blood, urine, and tumor tissue. If the tumor has not yet manifested itself in any way, the combination of subfebrile condition with specific changes in the blood has a diagnostic value. Often subfebrile condition accompanies chronic myeloid leukemia, lymphocytic leukemia, lymphoma, lymphosarcoma.

Other diseases

Can cause subfebrile condition and other diseases:

• autonomic dysfunction: disruption of the heart and cardiovascular system;
• dysfunction of the endocrine glands: hyperthyroidism and thyrotoxicosis (ultrasound of the thyroid gland and a blood test for hormones T3, T4, TSH, antibodies to TSH are detected);
• hormonal disorders;
• latent infection: Epstein-Barr virus, cytomegalovirus infection, herpetic infection;
• HIV infection (detected by ELISA and PCR);
• helminthiasis (detected by analysis of feces for worm eggs);
• toxoplasmosis (identified by ELISA);
• brucellosis (detected by PCR);
• tuberculosis (detected by Mantoux tests and fluorography);
• hepatitis (identified by ELISA and PCR);
• Iron-deficiency anemia;
• allergic reactions;
• thermoneurosis.

For infectious subfebrile condition are characteristic:

1. decrease in temperature under the action of an antipyretic;
2. poor temperature tolerance;
3. daily physiological fluctuations in temperature.

For non-infectious subfebrile condition are characteristic:

1. imperceptible flow;
2. lack of response to antipyretic;
3. no diurnal changes.

Safe subfebrile condition

1. Subfebrile temperature is completely safe during pregnancy, menopause and breastfeeding, which is simply a symptom of hormonal changes.
2. Up to two months and even six months, a temperature tail can persist after suffering infectious diseases.
3. Neurosis and stress may well provide a rise in temperature in the evenings. In this case, subfebrile condition will be accompanied by a feeling of chronic fatigue and general weakness.

Psychogenic subfebrile condition

Subfebrile condition, like any other processes in the body, is influenced by the psyche. With stress and neurosis, metabolic processes are primarily disturbed. Therefore, women often have unmotivated subfebrile fever. Stress and neuroses provoke an increase in temperature, and also excessive suggestibility (for example, about a disease) can affect the actual increase in temperature. In young women of the asthenic type, prone to frequent headaches and VVD, hyperthermia is accompanied by insomnia, weakness, shortness of breath, pain in the chest and abdomen.

To diagnose the condition, tests are prescribed to assess psychological stability:

• tests to detect panic attacks;
• scale of depression and anxiety;
• Beck scale;
• scale of emotional excitability,
• Toronto alexithymic scale.

According to the results of the tests, the patient is given a referral to a psychotherapist.

Medicinal subfebrile condition

Prolonged use of certain drugs can also cause subfebrile fever: adrenaline, ephedrine, atropine, antidepressants, antihistamines, antipsychotics, some antibiotics (ampicillin, penicillin, isoniazid, lincomycin), chemotherapy, narcotic painkillers, thyroxine preparations. Cancellation of therapy also relieves obsessive subfebrile condition.

Subfebrile condition in children

Of course, any parent will start to worry if their child has a fever every day in the evening. And rightly so, because in children, fever in some cases is the only symptom of the disease. The norm for subfebrile condition in children is:

• age up to a year (reaction to the BCG vaccine or unsteady processes of thermoregulation);
• the period of teething, when fever can be observed for several months;
• in children from 8 to 14 years old, due to critical growth phases.

About prolonged subfebrile condition, which occurs due to a violation of thermoregulation, they say if 37.0–38.0 ° in a child lasts more than 2 weeks, and the child at the same time:

• does not lose weight;
• examination shows the absence of diseases;
• all analyzes are normal;
• pulse rate is normal;
• temperature is not reduced by antibiotics;
• temperature is not reduced by antipyretics.

Often in children, the endocrine system is to blame for the increase in temperature. It often happens that in children with fever, the functionality of the adrenal cortex is impaired, and the immune system is weakened. If you draw a psychological portrait of children who have fever for no reason, then you get a portrait of an uncommunicative, suspicious, withdrawn, easily irritated child, whom any event can unsettle.

Treatment and the right lifestyle bring children's heat transfer back to normal. As a rule, after 15 years, few people have this temperature. Parents should organize the correct daily routine for the child. Children suffering from subfebrile condition should get enough sleep, walk and sit at the computer less often. Well trains thermoregulatory mechanisms hardening.

In older children, subfebrile temperature accompanies such frequent diseases as adenoiditis, helminthiasis, and allergic reactions. But subfebrile condition can also indicate the development of more dangerous diseases: cancer, tuberculosis, asthma, blood diseases.

Therefore, you should definitely consult a doctor if the child has a temperature of 37-38 ° C for more than three weeks. To diagnose and find out the causes of subfebrile condition, the following studies will be assigned:

• blood biochemistry;
• OAM, study of daily urine;
• feces on worm eggs;
• radiography of the sinuses;
• radiography of the lungs;
• electrocardiography;
• tuberculin tests;
• Ultrasound of internal organs.

If deviations are found in the analyzes, this will be the reason for referring narrow specialists for consultations.

How to measure the temperature in children

The temperature in children should not be measured immediately after waking up, after dinner, active physical activity, in an agitated state. At this time, the temperature may rise for physiological reasons. If the child is sleeping, resting or hungry, the temperature may drop.

When measuring temperature, you need to wipe the armpit dry and hold the thermometer for at least 10 minutes. Change thermometers periodically.

How to deal with subfebrile condition

To begin with, subfebrile condition should be diagnosed, because not every temperature increase in the specified range is precisely subfebrile condition. The conclusion about subfebrile condition is made on the basis of the analysis of the temperature curve, for the preparation of which temperature measurements are used 2 times a day at the same time - in the morning and in the evening. The measurements are carried out within three weeks, the results of the measurements are analyzed by the attending physician.

If the doctor diagnoses subfebrile condition, the patient will have to visit the following narrow specialists:

• otolaryngologist;
• cardiologist;
• infectiologist;
• phthisiatrician;
• endocrinologist;
• dentist
• oncologist.

Tests that will need to be passed to detect latent current diseases:

• UAC and OAM;
• blood biochemistry;
• cumulative urine samples and examination of daily urine;
• feces on worm eggs;
• blood for HIV;
• blood for hepatitis B and C;
• blood on RW;
• radiography of the sinuses;
• radiography of the lungs;
• otolaryngoscopy;
• tuberculin tests;
• blood for hormones;
• Ultrasound of internal organs.

Identification of deviations in any analysis becomes the reason for the appointment of a more in-depth examination.

Prevention measures

If the pathology in the body is not detected, you should pay close attention to the health of your body. To gradually bring thermoregulatory processes back to normal, you need:

• timely treat all foci of infection and emerging diseases;
• avoid stress;
• minimize the number of bad habits;
• observe the daily routine;
• get enough sleep in accordance with the needs of your body;
• exercise regularly;
• harden;
• walk more outdoors.

All these methods contribute to strengthening the immune system, training heat transfer processes.

Cholecystitis is an inflammation of one of the internal organs of the body - the gallbladder, it can be acute and chronic. Among diseases of the internal organs, cholecystitis is one of the most dangerous, because it causes not only severe pain, but also inflammatory processes and the formation of calculi, during the movement of which a person needs emergency surgical care, and if it is not provided in time, death can occur.

Chronic and acute cholecystitis, the symptoms and treatment of which we will describe in our article, are closely related to cholelithiasis and almost 95% of cases are diagnosed simultaneously, while determining the primacy of a particular disease is much more difficult. Every year the number of these diseases increases by 15%, and the occurrence of stones annually increases by 20% among the adult population. It is noticed that men are less prone to cholecystitis than women after 50 years.

How does cholecystitis manifest itself?

Cholecystitis is catarrhal, purulent, phlegmonous, perforative, gangrenous.

• Acute cholecystitis - causes

The most dangerous is the acute form of cholecystitis, which is accompanied by the formation of stones, both in the bladder itself and in its ducts. It is stone formation that is the most dangerous in this disease, this disease is also called calculous cholecystitis. First, the accumulation of bilirubin, cholesterol, calcium salts on the walls of the gallbladder form calcifications, but then with their prolonged accumulation, the size of the deposits increases and can present serious complications in the form of inflammation of the gallbladder. Often there are cases when stones enter the bile ducts and form serious obstacles to the outflow of bile from the gallbladder. This can lead to inflammation and peritonitis if the patient is not treated in time.

• Chronic cholecystitis - causes

Chronic cholecystitis is a longer current form of the disease. It is characterized by periods of remission and exacerbations. The development of pathology is based on damage to the walls of the bladder against the background of impaired evacuation of bile from it (hypo or hypermotor dyskinesia, pathology of the sphincter of Oddi). Secondarily, these factors are superimposed by a nonspecific bacterial infection that maintains inflammation or turns it into a purulent one.

Chronic cholecystitis can be calculous or non-calculous. In the first case, it is sand and stones that injure the mucous membrane of the bladder, clog the bile ducts or the neck of the bladder, preventing the outflow of bile.

Acalculous forms arise due to anomalies in the development of the bladder and ducts, their kinks, ischemia (in diabetes mellitus), tumors and strictures of the common cystic duct and bladder, irritation with pancreatic enzymes, obstruction of the ducts with worms, bile slugging in pregnant women, who quickly lost weight or receive full parenteral nutrition.

The most common microorganisms that cause inflammation are streptococci and staphylococci, as well as escherias, enterococci, and proteas. Emphysematous forms are associated with clostridia. Less commonly, chronic cholecystitis may be of viral origin, or be caused by a prototic infection. All types of infections penetrate the gallbladder by contact (through the intestines), lymphogenous or hematogenous route.

With various types of helminthic invasions, such as - with opisthorchiasis, strongyloidiasis, fascioliasis, partial obstruction of the bile duct (with ascariasis), symptoms of cholangitis (from fascioliasis) may occur, persistent dysfunction of the biliary tract is observed with giardiasis.

Common causes of cholecystitis:

• Congenital malformations of the gallbladder, pregnancy, prolapse of the abdominal organs
• Biliary dyskinesia
• Cholelithiasis
• The presence of helminthic invasion - ascariasis, giardiasis, strongyloidiasis, opisthorchiasis
• Alcoholism, obesity, an abundance of fatty, spicy foods in the diet, diet violations

With any type of cholecystitis, the development of inflammation of the walls of the gallbladder leads to a narrowing of the lumen of the ducts, its obstruction, to stagnation of bile, which gradually thickens. There is a vicious circle in which, sooner or later, a component of autoimmune or allergic inflammation appears.

When formulating the diagnosis of chronic cholecystitis, it is indicated:

• stage (exacerbation, subsiding exacerbation, remission)
• severity (mild, moderate, severe)
• the nature of the course (monotonous, recurrent often)
• state of gallbladder function (preserved, non-functioning bladder)
• nature of biliary dyskinesia
• complications.

Symptoms of acute cholecystitis

A provoking factor that gives points to the development of an acute attack of cholecystitis is powerful stress, overeating of spicy, fatty foods, and alcohol abuse. In this case, a person experiences the following symptoms of acute cholecystitis:

• Acute paroxysmal pains in the upper abdomen, in the right hypochondrium, radiating to the right shoulder blade, can rarely radiate.
• Increased fatigue, severe weakness
• A slight increase in body temperature to subfebrile numbers 37.2 -37.8C
• There is an intense aftertaste
• Vomiting without relief, persistent nausea, sometimes vomiting with bile
• empty burp
• The appearance of a yellowish skin tone - jaundice

The duration of acute cholecystitis depends on the severity of the disease, it can vary from 5-10 days to a month. In mild cases, when there are no stones and a purulent process does not develop, a person recovers quickly enough. But with weakened immunity, the presence of concomitant diseases, with perforation of the gallbladder wall (its rupture), severe complications and death are possible.

Symptoms of chronic cholecystitis

Chronic cholecystitis does not occur suddenly, it develops over a long time, and after exacerbations, against the background of treatment and diet, periods of remission occur, the more carefully the diet and maintenance therapy are followed, the longer the period of absence of symptoms.

The main symptom of cholecystitis is a dull pain in the right hypochondrium, which can last for several weeks, it can radiate to the right shoulder, and the right lumbar region, be aching. Increased pain occurs after taking fatty, spicy foods, carbonated drinks or alcohol, hypothermia or stress, in women, exacerbation may be associated with PMS (premenstrual syndrome).

The main symptoms of chronic cholecystitis:

• Indigestion, vomiting, nausea, lack of appetite
• Dull pain on the right under the ribs, radiating to the back, shoulder blade
• Bitterness in the mouth, belching bitterness
• Heaviness in the right hypochondrium
• subfebrile temperature
• Possible yellowing of the skin
• Very rarely, atypical symptoms of the disease occur, such as heart pain, swallowing disorder, bloating, constipation

For the diagnosis of both acute and chronic cholecystitis, the most informative methods are the following:

• cholegraphy
• duodenal sounding
• cholecystography
• Ultrasound of the abdominal organs
• scintigraphy
• A biochemical blood test shows high levels of liver enzymes - GGTP, alkaline phosphatase, AST, ALT.
• Diagnostic laparoscopy and bacteriological examination are the most modern and affordable diagnostic methods.

Of course, any disease is easier to prevent than to treat, and an early study can reveal early violations, deviations in the chemical composition of bile. And if you follow a strict diet, it will be enough for a long time to extend the period of remission of this disease and prevent serious complications.

Treatment of chronic cholecystitis

Treatment of a chronic process without the formation of stones is always carried out by conservative methods, the main of which is dietary nutrition (diet 5 - fractional nutrition with a sufficient volume of liquid, mineral water). In the presence of gallstones - limitation of hard work, physical overload, bumpy ride.

The following medicines are used:

• Antibiotics, most often broad-spectrum or cephalosporins
• Enzyme preparations - Pancreatin, Mezim, Creon
• Detoxification - intravenous infusion of sodium chloride, glucose solutions
• NSAIDs - sometimes used to relieve inflammation and pain

Choleretic drugs are usually divided into:

• Choleretics are drugs that increase the production of bile. Preparations containing bile and bile acids: allochol, lyobil, vigeratin, cholenzyme, dihydrocholic acid - chologon, sodium salt of dehydrocholic acid - decholine. Herbal preparations increase the secretion of bile: Flacumin, corn stigmas, berberine, convaflavin. Synthetic drugs: osalmid (oxafenamide), hydroxymethylnic otinamide (nikodin), tsikvalon, hymecromon (odeston, cholonerton, cholestyl).
• Cholekinetics are divided into: promoting the release of bile and increasing the tone of the gallbladder (magnesium sulfate, pituitrin, choleretin, cholecystokinin, sorbitol, mannitol, xylitol) and cholespasmolytic and reducing the tone of the biliary tract and the sphincter of Oddi: drotaverine hydrochloride, olimethin, atropine, platifillin, eufillin , mebeverine (Duspatalin).

During periods of exacerbation, phytotherapy is very widely used, in the absence of allergies to it - decoctions of chamomile, dandelion, peppermint, valerian, calendula. And during periods of remission, it is possible to prescribe homeopathic treatment or herbal medicine, but with other herbs - yarrow, marshmallow, tansy, buckthorn.

It is very important to follow a strict diet after an exacerbation of cholecystitis, then the symptoms gradually subside. In addition, it is also recommended to periodically carry out tubage with xylitol, mineral water or magnesia, physiotherapy is effective - reflexology, SMT therapy.

In case of calculous chronic cholecystitis with pronounced symptoms, it is recommended to remove the gallbladder, the source of the growth of stones, which can pose a threat to life when they move. The advantage of chronic cholecystitis with stones from acute calculous cholecystitis is that this operation is planned, it is not an emergency measure, and you can safely prepare for it. In this case, both laparoscopic surgery and cholecystectomy from a mini-access are used.

When surgery is contraindicated, sometimes in chronic cholecystitis, the treatment may be to crush the stones with shock wave lithotripsy, this extracorporeal procedure does not remove the stones, but simply crushes, destroys them, and often their re-growth occurs. There is also a method for the destruction of stones with the help of salts of ursodeoxycholic and chenodeoxycholic acid, in addition to the fact that this therapy does not lead to a complete cure, it is also quite long in time and lasts up to 2 years.

Treatment of acute cholecystitis

If acute cholecystitis is registered for the first time, stones and a severe clinical picture are not detected, there are no purulent complications, then it is sufficient to carry out standard medical conservative therapy - antibiotics, antispasmodics, NSAIDs, detoxification and enzyme therapy, choleretic agents.

In severe forms of destructive cholecystitis, cholecystotomy or removal of the gallbladder is mandatory (see. Most often, cholecystectomy is performed from a mini-access. If the patient refuses the operation, an acute attack can also be removed with medication, but it should be remembered that large stones necessarily lead to relapses and the transition to chronic cholecystitis, the treatment of which may still end in an operative way or cause complications.

To date, 3 types of surgical interventions are used to treat cholecystitis - open cholecystotomy, laparoscopic cholecystotomy, for weakened people - percutaneous cholecystostomy.

Without exception, all patients with acute cholecystitis are shown a strict diet - in the first 2 days you can only drink tea, then you are allowed to switch to a diet table 5A, where food is only steamed or boiled, a minimum of fat is used, fried, smoked, seasonings, carbonated and alcoholic drinks. More about that in our article.

Symptoms of cholecystitis depend on the cause that caused the inflammatory reaction, the age and gender of the patient. Women seek help several times more often than men.

Acute inflammation

The main causative agents of acute inflammation of the gallbladder are Escherichia coli, streptococci, staphylococci, Pseudomonas aeruginosa. In women, the infection can penetrate from the genitourinary organs with adnexitis, colpitis, etc. Acalculous and calculous cholecystitis are distinguished.

Complications of inflammation include:

• peritonitis;
• abscess;
• cholangitis;
• pancreatitis;
• lymphadenitis;
• dropsy;
• empyema;
• jaundice;
• sepsis.

Against the background of JCB

In women with obesity, acute inflammation of the gallbladder occurs more often. Acalculous cholecystitis develops mainly in men. Inflammation against the background of gallstone disease (GSD) is manifested by the following symptoms:

1. biliary colic. Localized on the right in the hypochondrium. Occurs more often at night or in the morning, grows and worries the patient for an hour. On examination, you can notice increased sweating.
2. Temperature increase. Usually the temperature is kept within 37-38 degrees. With a purulent process and melting of the bladder wall, the temperature reaches 39-40 degrees. It should be noted that in debilitated patients and the elderly, even with purulent processes, the temperature does not exceed 38 degrees.
3. Belching with bitterness, distension in the upper abdomen, bloating.
4. Obstructive jaundice caused by blockage of the duct by a stone.

On examination, the doctor finds the following symptoms:

• at the height of inspiration, when pressing on the right hypochondrium, the patient feels a sharp pain (Murphy's symptom);
• with light pressure on the bladder projection site, the patient notes soreness (Ker's symptom);
• the patient feels pain when the doctor taps on the edge of the costal arch on the right (Ortner's symptom).

Acalculous cholecystitis

The pathology is characterized by high mortality, as patients are in critical condition. Difficult diagnosis in severe cases is due to an erased picture and, in some cases, the absence of pain.

A feature of inflammation is a sudden onset, which is accompanied by severe pain (biliary colic). The symptom is caused by stretching of the bladder, an increase in pressure in it, and a violation of the outflow of bile. As a result of inflammation, the bubble swells and presses on the adjacent peritoneum.

In a patient, pain first occurs on the right, then it is given to the right shoulder, shoulder blade, and chest. Sometimes the pain mimics myocardial infarction, radiating to the left side of the chest. In some cases, patients complain of pain that radiates to the lower back. If the patient is not helped, after a few hours the symptoms intensify.

Colic forces a person to take a certain position - lying on his right side or back. The colic is accompanied by fever and chills - signs that are characteristic of purulent inflammation. The patient is constantly thirsty, he is disturbed by nausea and flatulence. Vomiting and constipation may occur.

On examination, the doctor reveals the following symptoms:

• plaque on a dry tongue;
• bloating;
• tension in the muscles of the anterior wall of the abdomen;
• enlargement of the gallbladder (sometimes not palpable);
• the bubble hurts when pressed;
• enlarged and painful liver.

In old age, there is a discrepancy between the clinical manifestations of inflammation and the severity of pathological changes in the wall of the gallbladder. In some cases, gangrenous processes occur against the background of an apparent improvement. The patient's symptoms subside due to the death of sensitive receptors.

The course of the disease and prognosis depend on changes in the bladder. Catarrhal inflammation in the treatment ends with recovery. With the development of the phlegmonous form, the disease is severe. The patient develops fever with chills, intoxication develops.

The patient complains of nausea, dry mouth. There is vomiting, sharp pains in the abdomen, bloating. The temperature may last for several days. With timely treatment, recovery occurs. In some cases, the pathology becomes chronic.

Severe form - gangrenous cholecystitis. In a patient, gas accumulates in the bladder, which is secreted by bacteria. Complications of pathology are:

• rupture of the gallbladder wall;
• wall melting;
• peritonitis.

When the wall breaks through, the patient develops severe pain, hiccups, flatulence, pressure decreases, gas and feces stop flowing. On examination, the doctor listens to the noise in the area of ​​the bladder. Often pancreatitis joins the disease, which complicates the diagnosis.

To clarify the diagnosis, laboratory and instrumental examinations are carried out. A clinical blood test shows leukocytosis, high ESR. Biochemical analysis indicates a moderate increase in bilirubin and transaminase activity (ALT, AST). Ultrasound reveals an increase in the wall of the bladder, the accumulation of exudate around it. When the wall melts in the bladder cavity, an accumulation of pus is found.

chronic form of inflammation

Chronic cholecystitis is less common in women than in men. Allocate inflammation acalculous and calculous. The inflammation may be purulent or catarrhal. Inflammation in acalculous cholecystitis is localized in the neck of the bladder.

The causes of inflammation are associated with exposure to bacteria or fungi:

• escherichia;
• staphylococcus;
• streptococcus;
• Pseudomonas aeruginosa;
• Proteus;
• shigella;
• mushrooms.

Chronic processes in the wall of the gallbladder occur with viral hepatitis A, B, C, D. Patients with bile stasis, changes in its composition and infections often suffer from pathology. The following factors play a role in the mechanism of the development of the disease:

• hypodynamia;
• malnutrition;
• allergy.

In women, congestion occurs during pregnancy. The occurrence of pathology in women can also be triggered by dieting and starvation.

During the course of the disease, 2 stages are distinguished - remission and exacerbation. The form is distinguished:

• sluggish;
• recurrent;
• purulent chronic cholecystitis.

Signs of cholecystitis depend on the severity of the course. A mild course is manifested by two exacerbations per year. Colic disturbs patients no more than four times a year. If relapses of the disease occur 4 times a year, they speak of moderate severity. The severe form is manifested by more than 5 relapses per year with frequent colic.

In a chronic course, several syndromes are distinguished:

1. Pain. Manifested by pain in the right hypochondrium. The nature of the symptom is a prolonged paroxysmal. The pain radiates to the right side of the body (sternum, shoulder, lower back). It occurs mainly with errors in the diet, after stress, overwork. Sometimes fever, weakness, pain in the region of the heart join the symptom.
2. Dyspeptic. The syndrome is manifested by belching, nausea, heaviness. The patient develops bitterness in the mouth, constipation, intolerance to fatty and fried foods; gases do not escape. There may be a feeling of "cola behind the sternum" after eating.
3. cholestatic. The syndrome is manifested by an increase in bilirubin in the blood. The patient's skin and sclera turn yellow, urine darkens, feces become discolored.
4. Asthenovegetative. The syndrome is manifested by excessive thinness of the patient. There is fatigue, irritability, sleep is disturbed.
5. Intoxication. With purulent processes, the temperature rises to 39-40 degrees, with normal catarrhal inflammation, the patient has a temperature of 37-38 degrees.
6. Intestinal. The syndrome is manifested by pain in the navel. May be accompanied by diarrhea or constipation.

Chronic inflammation can take place in different clinical variants:

• cardiac;
• arthritic;
• neurasthenic;
• subfebrile;
• hypothalamic.

In the cardiac variant, arrhythmia appears in patients, changes in the ECG are detected. After eating, aching pains in the heart may appear (especially when lying down). Arthritic variant is manifested by pain in the joints. The subfebrile variant can proceed with a temperature of 37-38 degrees for 2 weeks. Patients may experience chills.

The neurasthenic variant proceeds with the appearance of fatigue, irritability, malaise, sleep disturbance. Intoxication may occur. With the hypothalamic variant, trembling of the limbs, increased pressure, increased heart rate, angina attacks, swelling, and muscle weakness appear.

Xanthogranulomatous cholecystitis

A rare form of inflammation of the gallbladder, in which the walls of the organ thicken with the formation of cholesterol stones. The mechanism of development of pathology and the causes of occurrence are poorly understood. The disease is manifested by attacks of acute cholecystitis. Sometimes doctors observe a picture that is characteristic of chronic inflammation of the gallbladder.

Patients develop colic with pain radiating to the right shoulder and shoulder blade. Symptoms include belching, nausea, vomiting, bitterness in the mouth. Sometimes there is fever and chills. On examination, the doctor reveals pain in the projection of the gallbladder.

It should be noted that the disease often occurs against the background of gallstone disease. Stones are recommended to be removed. The patient is offered surgery (laparoscopy or cholecystectomy).

If there are problems with the gallbladder, a visit to the gastroenterologist should not be postponed, since complications of the pathology can lead to death. If there is a suspicion of acute cholecystitis, it is impossible to apply a heating pad, take analgesics and laxatives, or wash the stomach until the doctor arrives.