There are no specific symptoms of sludge syndrome, the disease often does not manifest itself in any way and is detected only by ultrasound. May be concerned:

  • pain in the right hypochondrium. They can be of varying intensity, intensify after eating, can be constant (pressing, pulling) or paroxysmal;
  • loss of appetite;
  • nausea during the day;
  • vomiting (often appears after eating, after a violation of the diet and diet, often with an admixture of bile);
  • heartburn;
  • stool disorders (diarrhea, constipation, alternating diarrhea and constipation).

Forms

By composition contents of the gallbladder sludge syndrome is divided into:

Endoscopic sphincterotomy has been shown to be effective in preventing further episodes of biliary pancreatitis as an alternative to cholecystectomy in patients with high risk. The indication for endoscopic retrograde cholangiopancreatography in patients with severe pancreatitis without significant cholestasis is controversial. So far, there is no evidence that therapeutic endoscopic retrograde cholangiopancreatography is required in all patients with biliary sludge during pregnancy.

Role therapeutic use endoscopic sphincterotomy in the treatment of pregnant patients with acute pancreatitis without common bile duct stones remains controversial. Some experts recommend placement of a biliary stent instead of performing a sphincterotomy and retrieval of stones, thereby eliminating the complications that accompany sphincterotomy. However, stenting carries the risk of stent occlusion and cholangitis and the need for a second procedure.

  • microlithiasis (small inclusions are detected in the gallbladder, when the position of the patient's body changes, there is a shift (in the gallbladder itself) of the level of suspension (the contents of the gallbladder, consisting of crystals of cholesterol (fat-like substance), calcium salts, protein) - determined by ultrasound (ultrasound) gallbladder;
  • clots of putty bile (self-displaced inside the gallbladder during ultrasound);
  • a combination of microlithiasis with thick (putty) bile.
By composition of the contents of the gallbladder:
  • cholesterol crystals predominate;
  • calcium salts predominate;
  • bilirubin inclusions predominate (bilirubin is a bile pigment (dye), a component of bile).
By development mechanism allocate primary and secondary sludge syndrome.
  • Primary sludge syndrome. Occurs as an independent disease, while it is not possible to identify any concomitant diseases.
  • Secondary sludge syndrome. Appears in the background various diseases and conditions, for example, against the background of alcoholic pancreatitis (inflammation of the pancreas), which develops in about 1/3 of patients, rapid decline weight, cholelithiasis (formation of stones in the gallbladder), etc.

The reasons

The reasons sludge syndrome.

In the third trimester of pregnancy, there is a three-fold increase in serum triglyceride levels. This is thought to be due to an estrogen-induced increase in triglyceride synthesis and a high secretion of low-density lipoprotein. Hypertriglyceridemia may be more severe in patients with familial hyperlipidemia predisposed to pancreatitis. Less common causes of acute pancreatitis that should be considered in the differential diagnosis are hypotheses during the first trimester, hyperparathyroidism, preeclampsia, genetic mutations, and acute pregnancy steatosis.

  • Rapid weight loss, diets (since this dramatically reduces the intake of fat with food, which stimulates bile flow, resulting in the formation of conditions for the formation of a sludge syndrome).
  • Operations on the stomach, intestines.
  • Reception of some medicines(cytostatics (drugs that stop cell division), antibiotics (antibacterial drugs for the treatment of infections), calcium supplements, etc.).
  • Sickle cell anemia (hereditary (transmitted from parents to children) a disease in which the structure of the hemoglobin protein is disturbed, as a result of which it acquires a characteristic sickle shape; in this disease, the functions of hemoglobin (oxygen transport) are impaired).
  • After transplantation of bone marrow, kidneys, liver and other organs.
  • Cholestasis in patients with hepatitis - inflammation of the liver (viral, alcoholic), alcoholic cirrhosis of the liver (a disease associated with the replacement of normal liver tissue with coarse connective tissue).
  • Alcoholic pancreatitis (inflammation of the pancreas) occurs in about 1/3 of patients.
  • Pancreatitis not associated with alcohol use (idiopathic).
  • With a combination of pathologies (diseases) - for example, the liver, pancreas, etc.
  • After removal of gallstones by shock wave lithotripsy (method of destruction (crushing) and removal of stones from the gallbladder and biliary tract).
  • Against the background of gallstone disease (formation of stones in the gallbladder).
  • Cirrhosis of the liver (replacement of normal liver tissue with coarse connective tissue).
  • Dropsy of the gallbladder (blockage of the cystic duct with a stone or its cicatricial narrowing up to obliteration (complete closure) of the lumen).
  • Long-term parenteral nutrition (intravenous administration of nutrients).
  • Diabetes mellitus (a disease that occurs due to a deficiency of the hormone insulin (pancreatic hormone, the main effect of which is to lower the level of glucose (sugar) in the blood)).
  • Sickle cell anemia (a hereditary disease in which the structure of the hemoglobin protein is disturbed, as a result of which it acquires a characteristic sickle shape; in this disease, the functions of hemoglobin (oxygen transport) are impaired).
  • After taking certain drugs (eg, antibiotics (antibacterial drugs used to treat infections)).
Allocate also risk factors development of sludge syndrome:
  • gender (more common in women);
  • age (over 55-60 years old);
  • heredity;
  • obesity;
  • nature of nutrition (the predominance in the diet of fatty, smoked products, bakery, pasta and etc.).

Diagnostics

  • Analysis of the anamnesis of the disease and complaints (when (how long ago) the symptoms of the disease appeared, whether abdominal pain bothers you, where they are localized (located), etc.).
  • Analysis of the life history: whether the patient has been taking any medications for a long time, whether he has diseases of the gastrointestinal tract (for example, hepatitis (inflammation of the liver), cirrhosis of the liver (a disease associated with the replacement of normal liver tissue with coarse connective tissue)), whether he abuses alcohol, etc.
  • Physical examination. Pain is determined on palpation (palpation) of the abdomen.
  • General blood tests, urine, feces to identify background (against which the sludge syndrome develops) and concomitant diseases, their complications.
  • Biochemical blood test to detect changes in liver enzymes (substances that speed up metabolic processes in the body), determine total protein, bilirubin (a component of bile), cholesterol (fat-like substance), etc.
  • Instrumental research methods.
    • Ultrasound examination (ultrasound) of the abdominal organs is the main method for diagnosing sludge syndrome. In this study, clots, flakes of bile in the gallbladder are detected, their number is determined, displacement (change in the level of bile depending on the position of the patient's body), the state of the walls of the gallbladder is assessed.
    • Duodenal sounding (a technique for obtaining bile from the duodenum 12) and the study of bile (microscopic examination of bile).
    • Computed tomography (CT) and magnetic resonance imaging (MRI) of the abdominal organs allow you to establish changes in the liver, gallbladder.
  • Consultation is also possible.

Sludge Syndrome Treatment

Depending on the functional state (ability to perform its functions) of the gallbladder and the severity of the sludge syndrome, all patients with newly diagnosed biliary sludge are conditionally divided into 3 groups:

Acute pancreatitis may also complicate the course of thrombotic thrombocytopenic purpura during pregnancy and pregnancy-induced hypertension. Drugs and alcoholism are extremely rare causes of acute pancreatitis during pregnancy. There are currently no official recommendations for gestational treatment of hypertriglyceridemia during pregnancy. Treatment of hyperlipidemic acute pancreatitis is predominantly favorable. It includes a low-fat diet, antihyperlipidemic therapy, insulin, heparin, and even plasmapheresis.

  • treatment is not required, the manifestations of sludge syndrome are moderate, treatment is aimed at identifying and eliminating the cause. It is recommended to follow the diet (table No. 5);
  • patients who require conservative (non-surgical) treatment;
  • patients requiring surgical treatment.
Conservative treatment.
  • Table number 5. Diet with fat restriction: it is necessary to exclude from the diet fatty meats, fish, cream, fatty sauces and mayonnaise, liver, eggs, limit flour and cereal products.
    • Allowed:
      • non-acidic fruit and berry juices, compotes, kissels, weak tea and coffee with milk;
      • wheat bread, rye bread, biscuits sweet dough;
      • fat-free cottage cheese, sour cream in a small amount, low-fat cheeses;
      • various soups on vegetable broth with the addition of vegetables, cereals, pasta;
      • butter and vegetable oil up to 50 g per day;
      • meat products from lean beef, chicken and other lean poultry, boiled or baked after boiling, cooked in a piece or chopped;
      • cereals;
      • vegetables, greens;
      • eggs (no more than 1 per day);
      • fruits and berries, except for very acidic ones;
      • sugar, jam, honey.
    • It is forbidden:
      • ​ pastry products (pancakes, pancakes, cakes, fried pies etc.);
      • cooking fats, lard;
      • soups on meat, fish, mushroom broths;
      • sorrel, spinach, radish, green onion, radish;
      • fatty meat (beef, lamb, pork, goose, duck, chicken);
      • fatty fish (sturgeon, stellate sturgeon, beluga, catfish);
      • fried and hard-boiled eggs;
      • pickled vegetables, canned food, smoked meats, caviar;
      • mustard, pepper, horseradish;
      • cranberries, sour fruits and berries;
      • ice cream, cream products, chocolate;
      • black coffee, cocoa, cold drinks;
      • alcoholic drinks.
  • Preparations containing UDCA (ursodeoxycholic acid) and bile acids are the drugs of choice for the treatment of cholestatic syndrome. They protect liver cells, bind and remove toxins (harmful substances) from them.
  • Antispasmodics (drugs that relieve spasms) to eliminate pain.
  • In the absence of the effect of the ongoing conservative treatment and high risk the development of complications that can threaten a person's life, removal of the gallbladder is indicated.

Complications and consequences

  • Acute pancreatitis (inflammation of the pancreas).
  • biliary colic (appearance of sudden cramping pain in the abdomen).
  • Cholestasis (stagnation of bile).
  • Acute cholangitis (inflammation of the bile ducts).
  • Cholecystitis (inflammation of the gallbladder).

Prevention of sludge syndrome

  • Normalization of body weight (however, it is worth remembering that you can not adhere to strict diets, starve, dramatically reduce weight).
  • Treatment of diseases against which biliary sludge has developed (for example, hepatitis (inflammation of the liver), cirrhosis of the liver (a disease associated with the replacement of normal liver tissue with coarse connective tissue)).
  • If possible, reduce the dose or refuse the medications taken that caused the sludge syndrome.

MGMSU, Moscow

He specializes in coloproctology and laparoscopic surgery. Certified by the European Association of Laparoscopic Surgery. Chief Assistant of the Department of Surgical Diseases of the Medical Faculty of the Thracian University. Gallstone disease is one of the most common health problems you may encounter.

Why exactly, who is most at risk, what symptoms and treatments we talk with Dr. Geo Tsivrovsky. Dr. Tsivrovsky, are there any patients who have bile problems more often? - These problems are more typical for women. In the United States, one in ten women has gallstone disease. This is less common in men.

The article is devoted to a discussion of a new type of pathology - biliary sludge, which was described due to the introduction of modern imaging techniques. This condition is an accumulation of cholesterol crystals, pigment crystals and calcium salts in the biliary tract and gallbladder. The issues of etiology, clinical manifestations and treatment of biliary sludge are discussed.

This is a very complex saturated solution in which water, acids, cholesterol and trace elements are in balance. Some of these factors are people with high blood cholesterol levels, overweight, and those who have had acute viral infections, severe dehydration, and even pregnancy. What viral diseases are involved? Even for a simple flu. This can cause an imbalance of electrolyte, water, which leads to impaired kidney and liver function. Even sudden body exhaustion or dehydration can be a turning point for stone formation.

Keywords: biliary sludge, sphincter of Oddi, bile lithogenicity, Rezalyut Pro.

About the author:

Polunina Tatyana Evgenievna - Doctor of Medical Sciences, Professor of Moscow State Medical University named after. A.I. Evdokimova

Biliary sludge. Algorithms of diagnostics, treatment regimens

T.E. Polunin

MSMDU, Moscow

The paper is dedicated to new pathology called biliary sludge, which was described with novel imaging techniques. This condition develops due to accumulations of cholesterol crystals, pigment crystals, and calcium salts in the biliary tract and gallbladder. The paper discusses etiology, clinical manifestations and treatment of biliary sludge.

How long does it take for stones to form? - It cannot be said, because it depends on the type of stones. How can you understand that there are problems with bile, what are the symptoms? - Most often it is pain, discomfort after eating, vomiting. And yellowing? - Yellowing is a very late symptom. Unfortunately, we are talking about the so-called complex biliary disease. This is not hepatitis, but yellowing due to occlusion of the bile ducts. What are the treatment options for the disease? There are many of them, but here we are not talking about conservative treatment.

Thus, it is impossible to take various medicines, herbs, which could lead to the dropping of stones. The only radical treatment is surgical removal and removal of the gallbladder with stones, because it no longer fulfills its role as a concentrated bile cattle. When damaged, it turns into a small bomb that is ready to explode for some reason, such as eating a lot of fat or spices and using some medicines. What advice can you give our readers to avoid developing gallstone disease? - First of all, they must be careful about the food and medicines they take.

keywords: biliary sludge, sphincter of Oddi, bile lithogenicity, Rezalut pro.

In connection with the introduction of ultrasound imaging techniques into clinical practice, a new nosological form of diseases of the hepatobiliary tract, “biliary sludge”, has appeared. Biliary sludge (from the Latin "biliaris" - bile and English "sludge" - mud, mud, ice porridge, silt, suspension) is an accumulation of cholesterol crystals, pigment crystals and calcium salts in one formation that occurs in the biliary tract and gall bladder ( Fig. 1). Biliary sludge (BS) occurs if there is stagnation of bile, it is stagnation that creates the conditions for its formation.

Lately, there are a lot of young people who are bodybuilding and taking supplements without realizing what they can do in the future. To be healthy, you must lead a normal and healthy lifestyle. In total, three types of stones were found in the gallbladder. When they are studied, their origin can be understood. The center of most stones is white and made up of cholesterol. Only after the stone had reached a certain size, as the infection began to accumulate additional layers of pigment or calcium.

Pure cholesterol stones. They are usually solitary, large, oval, about 25 cm in diameter or more. The colors are white or yellowish white. They are large enough to block the common bile duct. These stones are not radiopaque. When they are cut, their radiant crystal structure is visible.

Analysis of numerous studies shows that the frequency of detection of biliary sludge in different populations varies widely and is:
- in the general population among people who do not suffer from cholelithiasis - 1.7–4%;
- among those who complain about the digestive system - 7-8%;
- among persons presenting complaints characteristic of biliary dyspepsia - 24.4-55%.

Pure pigment stones These stones are composed of bilirubin and very rarely bilirudin. They are black, small, hard and irregular in shape. Not shadows on x-rays. Many of them, and most often, are the result of a disease that affects the composition of the blood. When they are carved, they look amorphous.

Mixed stones These are the most common stones, occurring in 80% of patients. They are usually transient and opaque to x-rays. The x-ray image shows a central translucent area surrounded by a dark shadow. The cut of this type of stone shows its multi-layered nature. They develop in clusters, sometimes up to 12 at the same time, and have faces to match each other in the gallbladder.

Most often, biliary sludge is detected in individuals with biliary pathology.

In the medical environment, there is an ambiguity of views on the clinical significance of BS. There are two points of view on the prognosis of BS. On the one hand, it seems that this is a transient condition that does not require treatment, on the other hand, it is initial stage cholelithiasis (GSD), characterized by an increase in the lithogenicity of bile and a decrease in the contractility of the gallbladder.

You can often hear that at 9 months, it is best to reduce foods that contain oxalates. These salts and esters of oxalic acid with bases. This acid is the simplest dibasic acid and is actually a colorless crystal. Oxalates like her. They cause the human body to form coarse oxalate and kidney stones, urinary tract, bladder and gallbladder and bile ducts, but rarely in the salivary glands. Most often stones and grains of sand are composed of calcium oxalate.

Why do some people suffer and others don't? Science today is not unanimous in answering this question. Some people have a birth defect in mineral metabolism, accompanied by the deposition of oxalates. This condition is called oxalate diathesis. Oxalate formation of sand and stones have been known since ancient times, but in the twentieth century, the incidence is increasing. In developed countries, about 30% of young people and adults suffer from this. She usually doesn't chase children. Women are more likely than men to have stones in the urinary system.

There are several classifications of this disease, based on the etiology, sonographic picture and chemical composition sludge.

Classification of Sporea Loan, taking into account the genesis of BS:
1. Primary BS (none of the following conditions have been identified).
2. Secondary BS:
- after shock wave lithotripsy for gallstones;
- with cholelithiasis;
- during pregnancy;
- with cirrhosis of the liver;
- with obstructive jaundice;
- with dropsy of the gallbladder;
- with long-term parenteral nutrition;
- at diabetes(non-alcoholic fatty liver disease);
- with sickle cell anemia;
- after taking ceftriaxone.

Well, here we are spared, but not completely ignored. However, gallstones are more common than the delicate stronger sex. How to form oxalate stones mostly calcium. A predisposing factor for them is more frequent use food products containing calcium oxalates. This happens especially often in the last months of pregnancy, when the uterus increases significantly and puts pressure on the kidneys, ureters, bladder and bile. This prevents the bladder from emptying urine and bile.

Frequent urination does not mean that the bladder is emptying completely, only that it irritates it because there is not enough urine. Hormones also take into account the formation of sand and stones. The increase in progesterone affects the kidneys, they are lazy and hide "from responsibility." Irritated, it shrinks and relaxes and bile, rather than function, stand in it, concentrate and the sludge becomes grit. Contraception also contributes to the formation of stones. All viral and bacterial infections of the urinary and biliary tract have a particularly favorable background for the deposition of oxalate crystals on the mucous membrane of these organs.

Classification of biliary sludge
1. Microlithiasis (small, up to 4–5 mm, hyperechoic inclusions without acoustic shadow, revealed
when changing the position of the patient's body).
2. Clots of putty bile.
3. Combination of microlithiasis with thick bile.

Composition of biliary sludge:
1. Cholesterol crystals in composition with mucin.
2. The predominance of calcium salts in the composition.
3. The predominance of bilirubin-containing pigments.

Lack of exercise also contributes to this process. It stimulates the creation of sludge due to the fact that the whole body, and in particular both the urinary and biliary systems, is lazy. urolithiasis disease has two phases: acute and latent. At the first stage, there is the presence of sand, but this does not cause an acute phase, i.e. colic, which is dramatic pain, is often compared to the pain of childbirth. crisis conditions during pregnancy may be accompanied by unwanted, effective, premature uterine contractions.

In the first months after childbirth, during colic, it slowed down the process of restoring the reproductive organs. Avoid foods rich in oxalates. The diet should not wear you down, but only to prevent the formation of stones. The main requirement is that the food must be selected. Rich in oxalates are cocoa and chocolate, rhubarb, spinach, nettle, sorrel, figs, potatoes, mature and green beans, plums, tomatoes, red grapes. An obligatory drink, but in moderation of various types of milk, dairy products and eggs.

A number of authors offer another version of the working classification:
1. According to the ultrasound form of biliary sludge:

  • echo suspension - the initial manifestations of sludge;
  • biliary sludge clots;
  • special forms (microcholelithiasis, cholesterol polyps of the gallbladder, putty bile with a "disabled" gallbladder).

2. According to the state of the contractile function of the gallbladder (assessed during dynamic scintigraphy): with preserved contractile function; with reduced contractile function; disabled gallbladder.
3. In combination with cholelithiasis: no stones in the gallbladder; with stones in the gallbladder.

Fried foods and fatty meats should not be present on the table. Sometimes you can afford to eat some forbidden foods, but they should not be in abundance. Drink plenty of fluids. They flush the kidneys, urinary tract, diluted urine and bile and prevent the precipitation of oxalates. Every day, drink up to five liters - tap or bottled water, lime, hip Hibiscus tea from St. John's wort, soups, juices of permitted vegetables and fruits. Reduce salt, but don't include it. This increases the concentration of urine and bile.

On the other hand, as an alternative, anti-inflammatory, so 5 g per day is sufficient and necessary. Vitamin A takes care of restoring the integrity of the epithelium of the mucous membrane of the genitourinary system, gallbladder and bile ducts, so there are foods rich in this vitamin, carrots, pumpkin, zucchini, cabbage, low-fat dairy products, milk with 2% fat. Green tea milk combo 1: This is an excellent drink in the fight against sand and stones from oxalate origin.

There are several stages in the formation of the BS:
• oversaturation of bile cholesterol;
• violation of the dynamic balance between pro- and antinucleating factors;
• nucleation and precipitation of cholesterol crystals;
• aggregation of crystals into microlites and their further growth.

Early diagnosis and treatment of BS pathology is of great clinical importance due to the possibility of BS transformation into chronic cholecystitis and gallstone disease.

Laboratory research:
- a clinical blood test: leukocytosis indicates an attachment to the functional disorders of the inflammatory process; its severity correlates with the severity of BS complications (cholecystitis, cholelithiasis) and affects the outcome;
- general urine analysis;
- coprogram (with cholepathies in the coprogram there are droplets of neutral fat plus a moderate amount of fatty acids, feces have a brilliant color, a tendency to constipation);
- bilirubin and its fractions;
– cholesterol;
- ALT (alanine aminotransferase);
- AST (aspartate aminotransferase);
- ALP (with an exacerbation of cholecystitis, a moderate increase in alkaline phosphatase, bilirubin, an increase in ALT);
– GGTP (gammaglutamyltranspeptidase);
– total protein and protein fractions;
- serum amylase;
- determination of the cholesterol index (the ratio between the content of bile acids and cholesterol in bile).

Instrumental examination:
– Ultrasound of the liver, gallbladder, pancreas;
- fractional chromatic duodenal sounding with microscopic and biochemical examination of bile;
- peroral and intravenous cholecystography;
- scintigraphy of the gallbladder and biliary tract;
- percutaneous transhepatic cholangiography (PCCH) - using a Hiba needle under ultrasound control, the needle punctures the bile duct and then a water-soluble contrast is injected; endoscopic retrograde cholangiopancreatography (ERCP) with SO manometry - allows to detect choledocholithiasis, SO strictures, primary sclerosing cholangitis;
- computed tomography - for the diagnosis of gallbladder tumors, metastases.

Functional disorders of the biliary tract, which lead to the formation of BS:
- primary dyskinesias, causing a violation of the outflow of bile and / or pancreatic secretion into the duodenum in the absence of organic obstructions;
- dysfunction of the gallbladder;
- dysfunction of the sphincter of Oddi;
- secondary dyskinesia of the biliary tract, combined with organic changes in the gallbladder and sphincter of Oddi.

The algorithm for diagnosing a patient with gallbladder dysfunction is shown in Fig. 2. The algorithm is a purposeful actions of a doctor to identify the pathology of the gallbladder and prescribe appropriate treatment or additional examinations.

Sphincter of Oddi dysfunction

Smooth circular muscles surrounding the ends of the common bile duct (choledochal sphincter) and the main pancreatic duct (pancreatic sphincter), and protecting them at the level of Vater's papilla, are called the sphincter of Oddi (Fig. 3).

SO dysfunction is characterized by a partial obstruction of the patency of the ducts at the level of the sphincter and can be both organic (structural) and functional in nature (impaired motor activity, tone of the sphincter of the common bile duct and / or pancreatic duct). Clinically, CO dysfunction is manifested by a violation of the outflow of bile and pancreatic juice.

SO stenosis is an anomaly with partial or complete narrowing of the sphincter of Oddi due to chronic inflammation and fibrosis (Fig. 4). The main conditions for the development of stenosis are: choledocholithiasis, pancreatitis, traumatic abdominal surgery, non-specific inflammatory bowel disease and rarely, duodenal juxtapapillary diverticulum.

SO dysfunction can lead to biliary colic. Up to one third of patients with unexplained biliary colic, especially after cholecystectomy, with normal extrahepatic biliary ducts and pancreatic ducts, have manometrically proven CO dysfunction. This type of dysfunction is caused by a cholecystokinin reaction leading to an increase in basal pressure or an increase in the amplitude and frequency of contractions.

At the heart of SO hypertension are most often psychogenic effects (stress, emotional overstrain), realized through an increase in the tone of the vagus nerve. The algorithm for diagnosing SO dysfunction is shown in fig. 5.

Clinical manifestations of SO dysfunction:
episodes of severe persistent pain. Localized in the epigastrium and the right upper quadrant of the abdomen;
pain episodes lasting more than 20 minutes, alternating with a pain-free interval;
recurring attacks for 3 or more months;
Stability of the pain syndrome that disrupts labor activity;
Pain may be associated with the following symptoms: onset after eating, onset at night, presence of nausea and/or vomiting;
Lack of data on structural changes in organs.

Given the differences in the clinical picture, patients with SO dysfunction are classified into three categories:
1. With isolated dysfunction of the sphincter of the common bile duct, biliary pain develops. The pain is localized in the epigastrium or right hypochondrium with irradiation to the back or right shoulder blade.
2. With predominant involvement in the process of the sphincter of the pancreatic duct - pancreatic. The pain is localized in the left hypochondrium with irradiation to the back, decreasing when bending forward.
3. In the pathology of the common sphincter - combined biliary-pancreatic pain. Pain girdle.

Laboratory and instrumental signs of SO dysfunction:
- changes in the level of hepatic and / or pancreatic enzymes (2-fold excess of the normal level of AST and / or -alkaline phosphatase at least in 2-fold studies);
- slowing down the excretion of the contrast agent from the choledochus during ERCP (> 45 min);
- Dilation of the choledochus (>12mm) or main pancreatic duct.

Currently, the most reliable method for studying SO function is endoscopic SO manometry. At the same time, separate cannulation of the choledochus and the Wirsung duct with manometry of their sphincters is possible, which makes it possible to identify a predominantly biliary or pancreatic type of disorders, as well as to establish the etiology of recurrent pancreatitis in patients who underwent cholecystectomy and papillotomy. Signs of SO dysfunction are: increased basal pressure in the lumen of the sphincters (above 30–40 mm Hg), increased amplitude and frequency of phase contractions (tachyoddia); increase in the frequency of retrograde contractions.

It should be borne in mind that long-term functional disorders in the biliary system can lead in the future to hypokinesia of the gallbladder with stagnation of bile, a violation of its colloidal stability, the formation of BS and the formation of gallstones. In addition, stagnation of bile against the background of dysfunction of the gallbladder mucosa can contribute to the attachment of infection, that is, it contributes to the occurrence of cholecystitis. The next important point is the predisposition to cholestasis syndrome. So, a long-term spasm of CO can lead to manifestations of cholestasis, secondary liver damage (cholestatic hepatitis, secondary biliary cirrhosis).

An increase in the lithogenicity of bile is most often due to a violation of the ratio of cholesterol, bile acids and phospholipids. In the presence of an excess of cholesterol, bile cannot be maintained in a solubilized state, which means that it precipitates in the form of cholesterol monohydrate crystals, creating the basis for the formation of BS. With preserved contractile activity of the gallbladder, agglomerated particles are evacuated into the duodenum through the sphincter of Oddi (see Fig. 3). Thus, the persistence of BS is possible only in conditions of biliary dysfunction of the hypokinetic type.

Treatment of biliary sludge

An indication for conducting courses of conservative therapy for BS, even if it is not accompanied by clinical symptoms, is its persistent detection, according to ultrasound data, for 3 months.

Depending on the characteristics of the clinical course of biliary sludge, the tactics of managing patients are also determined:
I - not requiring treatment, since the elimination of the etiological factor leads to regression of BS.
II - those in need of therapeutic treatment, because without appropriate treatment, BS is transformed into gallstones with the involvement of other organs and systems in the pathological process.
III - requiring surgical treatment, without which complications are possible that require urgent surgical intervention, with a high risk of purulent complications and mortality.

However, the choice of tactics of management and treatment in BS should be based not only on the characteristics of the clinical course, but also on the variants of biliary sludge diagnosed by ultrasound. In case of BS in the form of a suspension of hyperechoic particles (microliths), surgical intervention is not advisable. An exception can only be cases when, due to the long-term persistence of BS, a stricture of the terminal section of the common bile duct or stenosing papillitis is formed, which impede the outflow of bile. Clots of putty-like bile can cause blockage of the bile ducts in the narrowest places. These are the cystic duct and the distal common bile duct.

To obtain the maximum clinical effect, pathogenetic therapy for BS should influence the following main links of biliary lithogenesis:
• be accompanied by a decrease in the synthesis of cholesterol in the hepatocyte;
• stimulate the synthesis of primary bile acids;
• increase the excretion of cholesterol in the bile;
• restore the contractile function of the gallbladder;
• eliminate hypertonicity of the sphincter of Oddi;
• reduce the absorption of cholesterol in the intestine;
• promote the restoration of intestinal transit.

To reduce the lithogenic properties of bile by reducing the synthesis of cholesterol, there are currently a large number of drugs, which include the modern drug Rezalyut Pro. One of the properties of Rezalut Pro is its ability to reduce cholesterol in the blood and, accordingly, reduce the saturation of bile with cholesterol, by suppressing the synthesis of cholesterol in the liver. The clinical effect of Rezalut Pro therapy in BS is primarily due to a decrease in bile lithogenicity, which ultimately prevents the formation of microliths. The drug Rezalut Pro is prescribed at a dose of 2 capsules 3 times a day. The course of treatment depends on the form of biliary sludge. To eliminate biliary sludge in the form of a suspension of hyperechoic particles, a monthly course of treatment is usually sufficient. In other forms of BS, the course of treatment is longer, but, as a rule, does not exceed three months.

To improve the outflow of bile, choleretic drugs and, in particular, ursodeoxycholic acid (UDCA) are traditionally used.

To eliminate biliary dyskinesia, spastic pain, improve bile flow, symptomatic therapy with mebeverine is prescribed. In the presence of bile reflux into the stomach, antacids are recommended. A generalized scheme of BS therapy is shown in Fig. 1. 6.

The drug Rezalut Pro stabilizes the physicochemical properties of bile. The drug normalizes lipid metabolism, lowering cholesterol levels by increasing the formation of its esters and linoleic acid.

Currently, post-registration studies are ongoing to evaluate the effectiveness of Rezalut Pro in patients with diseases of the hepatobiliary and cardiovascular system to obtain an evidence base for the effect on the lipid profile.

Thus, the most optimal regimen in the treatment of biliary sludge in the form of a suspension of hyperechoic particles is the combination of Resalyut Pro and mebeverine. The applied scheme of treatment allows to eliminate the phenomena of dyscholia and dysmotility of the biliary tract, reduces the duration of treatment.

Literature

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