Place of choleretic drugs in clinical practice

Updated: 04/23/2021 15:29:32

Expert: Pogrebnoy Stanislav Leonidovich

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Digestion is a complete process, but it is divided into parts that seem opposite and incompatible. So, the stomach has a very acidic environment, and the duodenum is already alkaline. In order to reduce the acidity of gastric juice entering the intestines, and neutralize the activity of gastric enzymes, and transfer the change of phases of digestion from acidic to alkaline (intestinal), a special liquid is produced in the liver, which is called bile.

A little about bile

Our bile is produced by hepatocytes, or liver cells. Human hepatocytes are truly tireless workers, they work day and night. Hepatocytes neutralize harmful substances, synthesize antibodies and proteins, take part in the synthesis of coagulation factors, and in all types of plastic metabolism. And, in addition, they continuously produce bile.

Bile, formed in hepatocytes, at their biliary poles, gradually penetrates into increasingly larger intrahepatic ducts, finally into the common bile duct, and for consumption and storage it is transported to the gallbladder. The lining of the gallbladder has the ability to absorb water, and therefore the bile in the bladder is concentrated several times, and can be ten times stronger than the fresh one that was originally formed.

During digestion, bile gradually penetrates the duodenum and actively takes part in the digestion and absorption of fats. Bile enters the intestines using special mechanisms, both nervous and reflex. Cholecystokinin-pancreozymin, produced in the intestine, actively participates in them. As soon as stomach contents enter the intestine, cholecystokinin is released, causing the gallbladder to contract and empty. Moving through the intestines, most of the bile is absorbed through its walls, the rest is removed with feces, about 30% of the resulting bile. You can learn more about the physiology of digestion and bile.

What does our bile consist of?

about 70% of it are so-called bile acids: cholic, chenodeoxycholic, lithocholic, ursodeoxycholic and others. Bile contains quite a lot of phospholipids (more than 20%) and proteins (about 5%). Cholesterol is present in bile, about 4%, and bilirubin in the amount of 0.3%.

Bile acids are very important

. Firstly, it is the end product of cholesterol metabolism, and secondly, it is a very important means of digesting fats in the intestines. Bile acids cause emulsification and absorption because lipids, or fats, are water insoluble, but they are highly soluble in bile acids. The absorption of vitamins, which we classify as fat-soluble, also depends on the presence of bile acids in the intestines. These are vitamins A, D, E and vitamin K. If a person has a deficiency of bile acids, then he may have symptoms of vitamin deficiency of the above vitamins. The pancreas will also have difficulty working and digesting food, since pancreatic enzymes secreted by the pancreas are activated in the presence of bile.

It improves intestinal motility and increases the production of digestive hormones. Its role in binding and removing cholesterol from the body and the breakdown product of hemoglobin contained in the blood is very important. It's called bilirubin. Since this substance is not able to be filtered through the glomeruli, bilirubin is excreted through bile and also leaves the body with feces.

Every day, approximately a liter of this fluid is formed and excreted from the body of an adult. The bile of a healthy person is greenish or yellow in color and tastes extremely bitter.

Bile may not penetrate well into the duodenum for various reasons. This is the liver pathology itself, problems with the biliary tract, or their dyskinesia, the tendency of bile to form stones, or lithogenicity. And therefore, in order to correctly prescribe and use choleretic drugs, you need to know which part of the digestion they affect and where their “point of application” is.

Most often in clinical practice, conditions arise associated with the delayed formation of this fluid, with the difficulty of its entry into the small intestine, due to the development of cholelithiasis - stone disease, chronic inflammation of the bladder - cholecystitis and other pathologies of the pathways that excrete bile. The resulting chemical or mechanical obstacles to the normal passage of bile into the intestines cause a number of painful symptoms.

This is discomfort in the abdomen on the right, bitterness, nausea; in severe cases, obstructive jaundice, bloating, and discoloration of stool may occur. In order to normalize the passage of this important fluid, choleretic medications are used.

Stagnation of bile - what is it?

Some patients are firmly convinced that bile is produced and stagnates in the gallbladder. In fact, this is not entirely true. Bile is produced by hepatocytes, which are liver cells. From the liver, bile enters the gallbladder, where it reaches the concentration it needs by getting rid of excess water.

Bile is released from the gallbladder at the moment when food containing fats enters the human stomach. The organ begins to contract and bile enters the duodenum through the biliary tract. The hole through which it exits is located in close proximity to the hole through which the pancreas releases its enzymatic secretion into the duodenum.

Bile is needed by the body to solve the following tasks:

• Bile dilutes fats into an emulsion, which facilitates the “work” of the enzymatic mixture. It will be much easier for enzymes to dissolve such a fraction.
• Bile provides normal working conditions for pancreatic enzymes. Otherwise, they would not be able to fully dissolve food into essential nutrients.
• Bile causes the intestines to contract.
• Bile allows vitamins A, D, E and K, which are fat-soluble, to be absorbed.
• Bile prevents pathogenic microorganisms from entering the blood. It simply does not allow them to attach to the intestinal walls, and they are not able to be absorbed in the same way as food.
• Bile helps remove cholesterol, bilirubin and some hormones from the body. They pass through the liver and are excreted through bile along with feces.

Therefore, there is no doubt about the benefits of bile. However, in order for it to fully perform all its functions, it is necessary to provide conditions for its adequate formation and entry into the duodenum. If the body is unable to cope with this task, then choleretic drugs come to its aid. However, this does not mean that you can take all medications indiscriminately.

There are 4 groups of choleretic drugs.

Each group has specific goals and objectives:

1. Group 1: choleretics.

   These drugs are aimed at increasing bile production.

2. Group 2: cholekinetics.

   They accelerate the excretion of bile from the liver ducts, so it reaches the duodenum faster.

3. Group 3: cholespasmolytics.

   These drugs relieve spasm of the bile ducts.

4. Group 4: cholelitogenic bile acid preparations.

   They are necessary in order to dilute too concentrated bile and prevent stones from forming in it. Also, drugs from this group ensure the dissolution of small stones, which occurs due to changes in the properties of bile.

To choose one remedy or another, you need to know which process in the body is disrupted. Unjustified use of choleretic drugs can only aggravate the situation. For example, why relieve a spasm from the bile ducts if they are in a relaxed state or force the diseased liver to produce more bile when it is already working “for wear and tear”.

What are choleretic drugs?

Choleretic drugs are divided into two large groups, depending on their functions. The first is drugs that enhance the formation of bile and bile acids, and are called cholesecretics, or choleretics. They are prescribed when the mechanism of bile excretion is not affected, but there is a lack of its formation and a deficiency of bile acids. The second large group of choleretic drugs are cholekinetics, which promote a more active discharge of bile, first of all, from the gallbladder into the intestines, and, secondly, from the hepatic bile ducts into the gallbladder. It is clear that this division is rather arbitrary, since most choleretic drugs simultaneously enhance the formation or secretion of bile and significantly facilitate its flow to the gallbladder and further into the intestines.

List of cholelytics

Drugs from this drug group are used to prevent the formation of gallstones, as they reduce the concentration of cholesterol in bile. They can also be used to dissolve small stones.

Cholelytics include:

• Ursosan.
• Ursofalk.
• Ursodeoxycholic acid.
• Ursodes.
• Grinterol.
• Urdoxa.

The drug with the lowest cost is Ursodeoxycholic acid (600 rubles for 50 tablets). The most expensive drug is Ursofalk (915 rubles for 50 tablets).

Cholelytics are produced in capsule form. The daily dose is determined by the doctor. It depends on the patient’s weight and the presence of stones in the body.

Contraindications to taking cholelytics are: inflammation of the liver, inflammation of the gallbladder and bile ducts, pregnancy, lactation, calcium stones, biliary colic.

General contraindications to the use of choleretic drugs

Those contraindications for which choleretic drugs cannot be prescribed immediately become clear. Choleretics should not be prescribed for acute inflammatory processes in the liver, hepatitis, both alcoholic and autoimmune and viral. This is an inflammatory process in the area of ​​the gallbladder and bile ducts: cholecystitis and cholangitis, and not chronic, but acute processes. Unlike hepatitis, this may not be a therapeutic, but a surgical pathology.

Choleretics are not prescribed for pancreatitis, exacerbation of gastric and duodenal ulcers, erosive-ulcerative gastritis. Choleretics are prohibited in case of cholelithiasis. If the excretory ducts of the liver are blocked, and against this background the formation of bile is stimulated, the condition will worsen significantly. Contraindications include obstructive or obstructive jaundice, as well as degeneration of the liver parenchyma, for example, cirrhosis, when the formation of bile is difficult due to the defective functioning of hepatocytes.

Cholekinetics have a similar list of contraindications. Naturally, these are also acute diseases of the liver and biliary tract, cholelithiasis, exacerbation of gastritis with high acidity, as well as gastric ulcer. In other words, choleretic drugs should always be prescribed by a doctor, taking into account indications and contraindications.

List of choleretic drugs choleretics

All choleretics are divided into 2 types:

1. True choleretics.

   They increase the volume of bile, stimulating its formation in the liver. Depending on which substance is the basis of the drug, the following subtypes of true choleretics are distinguished:

   Preparations based on bile acids. They are obtained from animal bile.
2. Drugs of synthetic origin that are aimed at stimulating the formation of bile.
3. Preparations based on plant materials that activate processes leading to the production of bile.
4. Hydrocholeretics

   . These drugs are aimed at increasing the volume of the gallbladder, as they dilute it with water.

Below we will present drugs exclusively of synthetic or animal origin, as well as hydrocholeretics. Medicines based on herbal raw materials are listed under a separate heading.

Allohol

The drug is based on natural bile, and it is also supplemented with such components as activated carbon, garlic and nettle. As an alternative, the following products can be used: Cholenzyme (this drug has the addition of enzymes), Festal (its composition is similar to the composition of Cholenzyme) and Medical Bile in the form of an emulsion.

It is not always possible to use Allochol; it is not prescribed for exacerbation of hepatitis, and Festal and Cholenzym are not taken against the background of inflammation of the pancreas, with mechanical blockage of the bile ducts, as well as against the background of dystrophic changes in the liver tissues.

Allohol has a number of advantages. The drug allows you to cleanse the liver, removes toxins from the body, and quickly relieves the symptoms of dyskinesia. Allochol has been used as a medicine for many decades, so all its properties are thoroughly known to medicine. Allohol has been produced since 1964 and is the development of domestic specialists. This results in a low cost of the drug and protection against counterfeiting. Allohol is an extremely successful composition of plant and animal components, which allows you to solve many problems of the hepatobiliary system. In addition, the drug can be combined with other medications, for example, antiseptics, vitamins, laxatives. In addition to achieving a choleretic effect, Allochol is taken to prevent the formation of stones in the bile ducts.

As for the disadvantages of Allochol, they boil down to the fact that this drug still has a number of contraindications. First of all, this is true for acute inflammation of the digestive system.

Price for the drug: from 10 to 60 rubles.

Odeston

Odeston is based on Hymecromone. This substance is of synthetic origin. Analogues of this drug are medicines called Cholestil and Holonerton, but they are not on the market yet, as they are undergoing appropriate registration.

Odeston is not prescribed for blockage of the biliary tract, Crohn's disease, against the background of increased bleeding gums and gastric ulcers. Odeston should not be taken if there are serious problems with the kidneys, or during breastfeeding.

The main advantage of the drug is that it has a double effect, that is, it acts as a choleretic drug (eliminates heaviness and pain in the right hypochondrium, relieves the bitter taste in the mouth, nausea) and as an antispasmodic (relaxes the bile ducts and sphincter Oddie). Odeston is available in pharmacies without a prescription.

As for the disadvantages of the drug, these include the presence of contraindications in which the drug is prohibited from being taken. While biliary dyskinesia is often combined with various pathologies of the digestive system. Also, the disadvantages of Odeston include its high cost, which varies from 360 to 750 rubles, depending on the number of tablets in the package.

Nikodin

This is a drug based on a synthetic substance called hymecromone. Similar drugs are the drugs Cholestil and Holonerton.

Nicodin is not prescribed for blockage of the bile ducts, for gastritis with low acidity of gastric juice.

The advantage of the drug Nikodin is its pronounced choleretic effect. In addition, it has an antimicrobial and bactericidal effect, so it is prescribed for inflammation of the gallbladder. This means that Nikodin not only eliminates the symptoms of the disease, but also cures it.

At this point in time, this drug is at the stage of re-registration, so its cost is unknown. This is the most significant drawback of the drug. In addition, it is not prescribed for the treatment of pregnant women and children under 10 years of age.

In addition to the listed medications, mineral waters that have an alkaline environment can be considered hydrocholeretics, among them:

• Borjomi.
• Slavyanovskaya.
• Essentuki at numbers 4 and 17.
• Jermuk.
• Naftusya.

Review of choleretic agents

The use of choleretic drugs in the practice of a therapist and gastroenterologist is a pressing problem of modern medicine. This problem is described in some detail by the authors on the website of the Russian Medical Journal. Let us remind you that

scientific periodicals reviewed by the Higher Attestation Commission.

This list of choleretic drugs includes effective and quite often prescribed by gastroenterologists and therapists, both cholekinetics and choleretics. In the case of one active substance that has an international nonproprietary name (INN), it is given first, and only then the commercial or trade name of the drug. There may be several of them, both expensive, imported and more affordable domestic drugs.

As a rule, the most expensive drug on the list is the original one, that is, created for the first time; there is the largest amount of data, scientific research, clinical studies of effectiveness and safety on it. If possible, you should prefer the original drug, or, as a last resort, purchase generics from well-known manufacturers and in the middle price range. You should not buy the cheapest medications, since the quality of the substance used in this case may not be as high as that of the original drugs.

For each drug, the price range is given that is relevant for January-February 2021 for pharmacies of all forms of ownership on the territory of the Russian Federation. This list is not an advertisement or a pretext for purchase; the information is taken exclusively from official instructions for medicinal products that are publicly available. The prescription of any choleretic agent is the prerogative of the doctor, taking into account the established diagnosis, indications and contraindications.

The information below is for informational purposes only and cannot be used as an argument for prescribing medications without a doctor’s examination and self-medication. All drugs from this list exist in international and national clinical recommendations of gastroenterologists, and are included in the corresponding treatment algorithms and protocols. The review begins with choleretics.

List of cholespasmolytic drugs

Medicines in this group are:

Bellalgin

The composition of the drug includes belladonna extract, metamizole, soda and benzocaine. A similar drug containing belladonna extract is Atropine.

Bellalgin can cause serious side effects, so it is prescribed exclusively on medical advice. Most often, the patient is prescribed one tablet 2-3 times a day.

You should not take Bellalgin during pregnancy, against the background of tachycardia, with glaucoma, if there is a violation of the liver or kidneys, or against the background of hematopoietic disorders.

The obvious advantage of the drug is its low cost. For a package of 10 tablets you will need to pay 60 rubles. In addition to the fact that it has an antispasmodic effect, the drug helps eliminate pain.

The disadvantages of the drug include its multiple contraindications and side effects. Despite the fact that Bellalgin has an analgesic effect, it should not be taken for acute pain until the cause has been established.

Metacin

The basis of the drug is a substance called methocinium iodide. Metacin has no analogues. As a rule, patients are prescribed 1-2 tablets, 2-3 times a day.

You should not take the drug if you have diseases of the cardiovascular system, with reflux esophagitis, with a hernia of the diaphragm, or against the background of renal and liver failure.

The obvious advantage of the drug is that it can be prescribed for the treatment of pregnant women and children. In addition, Metacin has a pronounced analgesic effect, so it is allowed to be used to relieve renal colic. The price of the drug is not high and is within 180 rubles.

The downside of the drug is the presence of side effects, and quite serious ones, for example, paralysis of accommodation, urinary retention and increased intraocular pressure.

Platyfillin

The main active ingredient is platyphylline hydrotartrate. The drug has no analogues. It can only be used in the form of subcutaneous injections.

Platyfillin should not be prescribed to patients with atherosclerosis, heart disease, diaphragmatic hernia, or against the background of bleeding from the stomach or intestines.

The advantages of the drug include its low cost (for 10 ampoules you will have to pay 70 rubles), rapid elimination of pain and spasms. Moreover, this one is time-tested.

As for the disadvantages of Platiphylline, they include pain at the site of its administration. There is no possibility of oral administration, since the drug is released only in the form of a solution for injection.

Papazole

Papazole is a drug based on papaverine hydrochloride and bendazole. Similar drugs include Dibazol, Papaverine in suppositories and injections.

Take Papazol one tablet 2 or 3 times a day.

The drug should not be used to treat patients with low blood pressure or the elderly.

The advantages of the drug include its extremely low cost (10 rubles per package containing 10 tablets), as well as the combined effect. In addition to the antispasmodic effect, Papazol is able to stimulate the immune system, lower blood pressure and relax vascular walls that are in hypertonicity.

The disadvantages of the drug include the presence of contraindications and side effects. It is not prescribed to patients suffering from renal failure. In addition, Papazol can interact with many medications, so only a doctor can recommend its use.

Drotaverine

The main active ingredient is drotaverine. An analogue of this drug is No-shpa.

Take the drug 1-2 tablets no more than three times a day. Drotaverine should not be prescribed to patients suffering from atherosclerosis and glaucoma.

Drotaverine is an inexpensive medicine of domestic origin, its cost does not exceed 70 rubles per package. Also, the advantage of the drug is its speed of action, the duration of the analgesic effect and high bioavailability, which is equal to 100%.

As for the disadvantages of Drotaverine, these include only the side effects that it can give. First of all, this concerns a sharp decrease in blood pressure and depression of the respiratory center. In childhood, the drug can only be used in tablet form.

Duspatalin

The main active ingredient is mebeverine. An analogue of Duspatalin is the drug Mebeverine. It is taken one capsule twice a day.

The drug is not prescribed to children under 10 years of age, or to pregnant women.

As for the advantages of the drug, these include quick relief of spasms and targeted effects. Duspatalin can be taken for two weeks without consulting a specialist, but provided that the person has no contraindications to it.

The disadvantages of the drug include its high cost and side effects. For packaging you will need to pay from 510 to 600 rubles.

Eufillin

The main active ingredient is aminophylline. An analogue of Eufillin, the drug Aminophylline, is currently undergoing re-registration.

Patients are prescribed Eufillin 1 tablet 3 times a day.

The drug should not be used against the background of myocardial infarction, arrhythmia or other heart diseases. It is not prescribed for acute gastric ulcers. It is also contraindicated in children under 6 years of age, patients with epilepsy and hyperthyroidism.

The price of Eufillin is low and amounts to 20 rubles. Also, the advantages of the drug include its speed of action and a small number of side effects.

The disadvantage of the drug is the presence of contraindications, which are mainly associated with diseases of the cardiovascular system. Therefore, most cardiac patients simply will not be able to use Eufillin to relieve spasm and pain.

Galidor

The main active ingredient is bencyclane. The drug has no analogues. You need to take one tablet 3 times a day.

The drug is not prescribed for myocardial infarction. It is contraindicated in people under the age of 18, as well as in patients with epilepsy and hyperthyroidism.

The advantages of the drug include the rapid provision of an analgesic effect. It can be used by patients suffering from cholecystitis and cholelithiasis. The drug is prescribed to people who have undergone surgery to remove the gallbladder and for dyskinesia of the sphincter of Oddi.

The downside of Galidor is its high cost. For a package of 50 tablets you will need to pay 550 rubles. In addition, the drug cannot be used to treat pregnant and lactating women, as well as for liver failure.

Buscopan

The main active ingredient is hyoscine. The drug has no analogues. It is not prescribed for urolithiasis, atherosclerosis and glaucoma.

The advantages of the drug include its pronounced antispasmodic effect (occurs 15 minutes after administration) and a decrease in the production of digestive secretions, which is very important for choleretic drugs. At the same time, Buscopan has no effect on the central nervous system.

The only drawback of the drug is its high cost. It varies in the range of 360-380 rubles.

Choleretic - choleretics: stimulants of education

The most well-known mechanism of action of choleretics is the receipt of reflexes from the intestinal mucosa. This is especially true for medications containing natural bile, namely bile acids. They have a remarkable effect on increasing the secretion of bile by hepatocytes. In addition to the general increase in the amount of bile, the content of bile acids in it increases, and the gradient between bile and blood, being an osmotically active value, increases the filtration of water and electrolytes into the bile capillaries. Bile begins to move faster through the bile ducts, which reduces the possibility of its stagnation, cholesterol precipitation and the formation of gallstones. Thus, choleretics are not only drugs that prevent gallstone disease, but also drugs that increase the ability of digestion to digest fats and improve motility of the small intestine.

Agents that stimulate the formation of bile from its precursors can be natural, or true, synthetic, as well as herbal choleretic agents that have a bile-forming effect. True choleretics are often products of animal origin. The most popular choleretic drugs from all subgroups will be listed below. Of these, Allochol is a true choleretic, Odeston is a synthetic drug, and Holosas is a choleretic drug consisting of one herbal component.

Allohol

Rating: 4.9

Allochol is perhaps the most popular and accessible “folk” choleretic medicine. This is a combined remedy, and Allochol contains dry cattle bile, dry nettle and garlic, as well as activated carbon. All these components together give a stronger choleretic effect than just bile alone. Allochol is able to increase contractions (peristalsis) of the intestines, and due to the presence of activated carbon, which has an antimicrobial and sorption effect, it reduces the processes of putrefaction and fermentation that can occur in the intestines.

Allochol is indicated in the complex therapy of chronic cholecystitis, cholangitis, and atonic constipation. It is usually taken in two tablets, after meals, so that it has the maximum choleretic effect. If the patient is prescribed fractional meals, then the drug should be taken no more than 4 times. This intake must be followed for a month, and then the dosage is halved. The course can be repeated, but between them it is necessary to take breaks of at least 2 months.

Allochol is produced by the domestic company Pharmstandard, and a large package containing 50 film-coated tablets costs only 42 rubles. In some pharmacies you can find it for 33 rubles, and the smallest package of 10 tablets costs only 12 rubles.

Advantages and disadvantages

Allochol works, “choleretic” quite mildly, unlike synthetic drugs. After all, it contains natural bile. But, nevertheless, at a sufficiently high dosage it can cause diarrhea and abdominal flatulence, and Allochol is contraindicated in acute ulcers, mechanical (obstructive) jaundice, and if there are stones in the gallbladder. This leads to a sharp increase in secretion, and if there is nowhere for it to go, then the bladder may expand and even rupture with the development of peritonitis. Allochol is contraindicated in acute and subacute hepatitis - inflammation of the liver, and in its progressive dystrophy. But this choleretic drug, taken according to indications, acts gently and helps improve digestion and normalize stool in a wide variety of groups of patients.

Gimecromon (Odeston)

Rating: 4.8

Odeston belongs to the group of infrequently used synthetic choleretics, and it has a fairly pronounced choleretic effect. This product contains hymecromone in the form of an active substance, and is available in the form of tablets weighing 200 mg each.

Odeston reduces the phenomenon of stagnation, reduces the processes leading to the formation of cholesterol stones, that is, reduces the loss of cholesterol in the form of crystals, and is indicated in the treatment of diseases such as biliary dyskinesia of the hyperkinetic type, chronic cholecystitis and cholangitis. It is prescribed after surgery on the gallbladder, and due to a chronic decrease in bile secretion.

Odeston is used half an hour before meals, 1 or 2 tablets, three times a day. The daily dose should not exceed 6 tablets. The course of treatment is about 2 weeks. It is not recommended to skip a dose, but you should not make up for it later by taking a double dose at once. Odeston is produced by the Polish company Polfa.

Advantages and disadvantages

Like all choleretic drugs, Odeston has contraindications. These include obstruction formed in the bile ducts, the phenomenon of renal and liver failure, gastric ulcers, bleeding disorders and childhood. The drug has side effects due to its rather strong choleretic effect. This can lead to bloating, diarrhea, allergic reactions and abdominal pain. Since the product is synthetic, many doctors note, along with its strong effect, that it is somewhat rough: Odeston is not intended for mild stimulation.

Holosas and other herbal remedies

Rating: 4.8

Herbal choleretic drugs have a complex and complex effect on the gastrointestinal tract as a whole and on its organs individually. They contain phytosterols, essential oils, phytoncides, sometimes vitamins, flavones and various resins. For example, Holosas, like rosehip syrup, immortelle and Holagol increase the secretion of bile, while simultaneously improving its fluidity, that is, reducing viscosity.

Also, plant components increase the content of chelates, or bile acids, in bile. These drugs can increase the tone of the gallbladder muscles, and at the same time relax the smooth muscles of the bile ducts, as well as the sphincters of Oddi and Lutkens. Choleretic agents improve the secretion of the stomach and pancreas, improve the quality of gastric juice enzymes, and when intestinal tone decreases, they improve peristalsis. Some components, for example, tansy and mint have an antimicrobial effect, and rose hips have an anti-inflammatory and diuretic effect. Usually, various tinctures and extracts are classified as choleretic, but you can also prepare decoctions from herbal collections. They should be used half an hour before meals 3 times a day, respectively, with more frequent and smaller meals, the frequency and dosage of choleretic herbal remedies is determined by the doctor.

Perhaps, Holosas is one of the most delicious and pleasant medicines in general, since it is a concentrated syrup of rose hips with sugar. In some cases, if it is not hidden from small children, they may drink the entire bottle, and after that they will suffer from profuse diarrhea due to an overdose, but still, nothing bad will happen to them anymore.

Holosas is indicated for various viral hepatitis, for inflammation of the bile ducts and bladder, for poisoning with various drugs, medications that are metabolized, secreted into bile, it is indicated for poisoning with alcoholic beverages. Holosas can be prescribed as a general tonic and for vitamin C deficiency.

It should be used 2 to 3 times a day, adults - 1 teaspoon per dose, and children - half a teaspoon or even less. Holosas is produced by the domestic company Altaivitamins CJSC, and the cost of one 140 ml bottle is on average 140 rubles.

Advantages and disadvantages

Holosas is a natural herbal monomedicine, and the only contraindications will be individual intolerance, as well as severe diabetes mellitus, since Holosas contains sugar. The drug has no side effects, again with the exception of individual intolerance. Few people will experience unpleasant side symptoms from the delicious rosehip syrup. This remedy is inexpensive, Holosas can be added to boiling water and drunk for general strengthening purposes. Taking one teaspoon of Holosas completely satisfies the daily need for ascorbic acid.

Sibektan

Rating: 4.8

Sibektan is a complex herbal medicine produced by the domestic company Pharmacenter Vilar. It contains dry extracts of birch, St. John's wort, silymar extract (or dry extract of milk thistle fruits), dried flowers of common tansy, or tanacehol extract. The drug, in addition to its choleretic effect, protects liver cells, has a hepatoprotective effect, as well as a membrane stabilizing and antioxidant effect.

It can be used for hypotonic type gallbladder dyskinesia, chronic cholecystitis and chronic persistent hepatitis. The drug is also used in the complex treatment of liver cirrhosis and fatty degeneration of alcoholic origin. For adults, the drug is prescribed two tablets 4 times a day for a month, Sibektan is taken 20-40 minutes before meals.

Advantages and disadvantages

The drug is relatively inexpensive, has a mild effect; among the contraindications, general contraindications to choleretic drugs should be taken into account, that is, cholelithiasis. Sibektan is not used in children under eighteen years of age; the drug is not prescribed to pregnant and lactating women, as well as to persons with individual intolerance. Otherwise, the drug containing choleretic herbs is very good, but not as a monotherapy, but in complex therapy, for example, with the same bile acids.

Ursodeoxycholic acid (Ursosan, Ursofalk, Urdoxa, Ursodez)

Rating: 4.8

Ursosan is a representative of a large group of drugs containing bile acids. They improve bile levels, the bile-forming function of hepatocytes increases, and these drugs not only prevent cholelithiasis, but also in some cases dissolve existing cholesterol stones in the gallbladder. UDC, or ursodeoxycholic acid, which is part of Ursosan, also lowers the cholesterol content in bile. And one of the important indications for prescribing this remedy will be the dissolution of gallstones, if they are small in size and consist of cholesterol. You can try to treat the patient conservatively, or you can supplement Ursosan with a surgical or shock wave (distant lithotripsy) method of treating cholelithiasis.

Ursosan is produced by Promed Prague, from the Czech Republic, and capsules containing 250 mg of ursodeoxycholic acid will cost from 750 to 850 rubles. per pack of 50 capsules. The drug can be used for uncomplicated gallstone disease, for the prevention of recurrent stone formation, for various forms of chronic hepatitis, and even for primary biliary cirrhosis and primary sclerosing cholangitis. The medicine is indicated in the complex disease of non-alcoholic and alcoholic fatty liver, for the treatment of chronic viral hepatitis and for biliary dyskinesia.

The medicine should be prescribed in various dosages. So, to dissolve cholesterol stones, a patient can be given Ursosan up to 15 mg per kilogram of weight, that is, a patient weighing 100 kg will receive 1500 mg daily, or one and a half grams, or 6 tablets. Accordingly, after 8 days the package of 50 tablets will run out. And the dissolution of stones is an indication for long-term treatment: 6 months, and even one year, until the stones are completely dissolved. Therefore, the patient uses four packages in a month, and a monthly course of treatment will cost more than 3,000 rubles, so it is necessary to immediately assess your financial capabilities.

There is also Ursosan Forte, when the tablets contain twice the dosage: 0.5 g. The largest package of 100 such tablets will cost an average of 3,000 rubles, produced by the same company. Similarly, this package will also last a patient weighing 100 kg for a month, 3 tablets per day.

For chronic hepatitis and pathologies of the biliary tract, there are similar dosages, which are calculated by the doctor also depending on body weight.

Advantages and disadvantages

In some cases, long-term intake of bile acids significantly improves digestive function and quality of life in many diseases, for example, viral hepatitis and cirrhosis. However, the contraindication would be:

1. the presence of X-ray positive calcium gallstones that will not dissolve;
2. non-functioning gallbladder;
3. decompensated stage of liver cirrhosis, when only a liver transplant can save a person;
4. acute inflammatory diseases of both the bile ducts and bladder, and the intestines;

Ursosan is not prescribed to children under three years of age.

The most common side effects were diarrhea or softening of the stool. The medicine should not be taken for chronic and acute liver and kidney failure, as well as for gallstones of non-cholesterol origin. But cholesterol stones must also be small, up to 2 cm, and the patency of the cystic and common bile duct must be preserved to maintain effective bile dynamics. During the treatment of cholelithiasis, as prescribed by a doctor, liver transaminases - ALT and AST are regularly determined, and the effectiveness of treatment is monitored according to ultrasound of the gallbladder. Ursodeoxycholic acid is a product with internationally proven effectiveness:

Treatment options for biliary dyskinesia

THEM. SHCHERBENKOV

,
Multidisciplinary clinic "Center for Endosurgery and Lithotripsy", Moscow The biliary tract is a complex bile excretion system, including the common hepatic duct, the gallbladder with the Lütkens sphincter, the common bile duct and the biliary-pancreatic ampulla with the sphincter of Oddi.
A distinctive feature of the bile formation process is its continuity. However, the entry of bile into the intestines occurs only during the digestion process. This is ensured by the reservoir function of the gallbladder and its rhythmic contractions with sequential relaxation of the Lutkens and Oddi sphincters. The parasympathetic and sympathetic parts of the autonomic nervous system, as well as the endocrine system (gastrointestinal hormones), take part in the regulation of this process, providing a synchronized sequence of contraction and relaxation of the gallbladder and sphincter apparatus. Synchronicity disturbances in the functioning of the gallbladder and sphincter apparatus underlie dysfunctional disorders of the biliary tract.

The term “biliary dyskinesia” (BDSD) is commonly understood as a complex of disorders of the biliary system caused by impaired motor function of the gallbladder (GB) and bile ducts in the absence of their organic changes. This condition is associated with dysfunction of the smooth muscle fibers of the extrahepatic bile ducts, which carry out the evacuation of bile into the duodenum. JVP includes different types of changes in motor function, which cannot always be strictly divided. The classification of functional gastrointestinal disorders and, in particular, biliary tract disorders has been revised several times. The latest classification of functional biliary disorders was proposed by the Rome III Consensus in 2006.

There are primary and secondary JVP:

– primary bile duct is relatively rare and is observed in the absence of organic changes in the gallbladder and extrahepatic bile ducts.

Long-term primary bile duct can cause stagnation of bile in the gallbladder, which disrupts its colloidal stability and contributes to the occurrence of the inflammatory process and stone formation in the biliary system.

– secondary biliary diarrhea refers to movement disorders caused by interoceptive influences from neighboring organs, especially in conditions of pathology of the latter, and is considered as a reaction of the biliary system to pathological processes occurring primarily in the abdominal cavity. It is observed in systemic diseases, hormonal disorders, cholelithiasis, and in the formation of postcholecystectomy syndrome. Etiology and pathogenesis

The following reasons for the development of dyskinesias of the extrahepatic biliary tract can be identified:

1) reflex influences (pathological interoception); 2) disorders of neurohumoral regulation; 3) endocrine factors; 4) psychogenic influences.

Psychogenic dyskinesias are a local manifestation of general neurosis and are often combined with functional disorders of other parts of the body. Long-term functional disorders lead to the development of organic lesions of the biliary system. Thus, JVP, especially hypotonic ones, causing stagnation of bile, cause a violation of its colloidal stability, absorption function of the bladder, activation of the peroxidation mechanism, which entails a chain of changes in the system of bile formation and bile excretion, creating a vicious circle. Thus, the JVP is one of the obligatory factors involved in the formation of biliary lithogenesis.

Clinical symptoms

Clinical manifestations of primary VSD: • the onset of the disease is acute; • recurrent course; • main symptoms – pain, dyspepsia, neurotic manifestations.

The first signs of the disease most often appear after strong emotional stress or when exposed to other neuropsychic factors. Among patients with this pathology, young women, asthenic physique, and poor nutrition predominate. A combination with hormonal disorders (menstrual irregularities, hyperthyroidism, etc.) is typical. Most patients experience pronounced neurotic symptoms - irritability, tearfulness, short temper, palpitations, headaches, etc. Pain is the main symptom of ADHD. According to the diagnostic criteria for functional disorders of gastrointestinal tract and sore throat (Rome Consensus III, 2006), pain episodes localized in the epigastrium and/or in the right upper quadrant of the abdomen include:

• episodes of pain last 30 minutes or more; • pain is moderate or severe, interferes with daily activities or may lead to hospitalization; • pain intensifies or remains constant; • pain does not decrease after stool; • pain does not decrease when changing position; • pain does not decrease after taking antacids; • symptoms may recur at varying intervals (not daily); • structural diseases that could explain the symptoms have been excluded.

Confirming criteria include cases when:

– pain is associated with nausea or vomiting; – pain radiates to the back and/or right subscapular region; – the pain wakes you up in the middle of the night.

The nature of the pain depends on the form of dyskinesia. Hyperkinetic, hypertonic forms of ADHD are characterized by an acute onset. The intensity of pain ranges from minor, dull, to severe, reminiscent of biliary colic. An intense attack of pain is accompanied by autonomic reactions: a feeling of palpitations, a feeling of numbness in the limbs, fear, urinary retention followed by copious urine output, often headaches, pain in the heart.

With strong vegetative symptoms, the abdomen is usually soft, there is no tension in the right rectus abdominis muscle, gall bladder reflexes are not expressed, and sometimes there is moderate pain in the area of ​​​​the projection of the gallbladder. There are no general manifestations of inflammation (fever, chills, increased ESR, leukocytosis with band shift).

Hypomotor, hypotonic forms of VADP are characterized by a feeling of heaviness and moderate pain in the right hypochondrium. Nausea, bitterness in the mouth, bloating, and constipation occur. This group of patients is characterized by excess body weight.

In all forms of diarrhea, dyspeptic symptoms are observed. There is a violation of predominantly cavity digestion, caused by, and with the progression of the disease, a violation of parietal digestion occurs, a violation of absorption, which leads to the appearance of dyspepsia. There is a decrease in appetite, a feeling of bitterness in the mouth, stool disorders, and flatulence. Patients often experience constipation, but more often they experience diarrhea or constipation alternating with diarrhea. With the intensification of these disorders, a decrease in body weight, the development of hypovitaminosis, and protein deficiency are possible. Weakness, irritability, and decreased performance indicate a lack of vitamins B, K, and A.

Clinical manifestations of secondary VSDs

The clinic is diverse, which is due to interoceptive impulses from the abdominal organs. Reflex impulses from a diseased organ (stomach, duodenum, pancreas, appendix, etc.) can cause motor and secretory disorders of the biliary system, changing the clinical picture of the disease. Often, manifestations of hyperkinetic JP, especially with severe pain symptoms, dominate the clinical picture, masking the manifestations of the underlying disease.

In chronic gastritis, changes in the biliary tract are observed in 50% of cases. With secretory insufficiency, hypomotor dyskinesia of the gastrointestinal tract is observed in combination with hypertonicity of the sphincter of the gastrointestinal tract; with increased secretory function of the stomach, hypermotor dyskinesia of the gastrointestinal tract and sphincter hypotension are observed.

In case of duodenal ulcer with frequent exacerbations and a duration of more than 5 years, patients are diagnosed with chronic cholecystitis with a predominantly hypotonic form of gastric dyskinesia.

Reflexes from the biliary tract when they are damaged cause dyskinetic disorders of the duodenum, manifested in impaired tone and motor function of the intestine. More often these are hypertensive dyskinesias with pronounced spastic reactions.

With a short history of cholecystitis, the hyperkinetic type of dyskinesia predominates; as the disease progresses, hypotension of the gallbladder and hypokinesia of the ducts prevail. The addition of dyskinesia is an aggravating factor that contributes to the persistent course of chronic cholecystitis.

Diagnosis of JVP

The diagnosis of PVD is based on clinical symptoms, X-ray and ultrasound data, as well as fractional duodenal intubation.

In patients with primary dysfunction of the gallbladder, a clinical blood test, liver tests, and the content of pancreatic enzymes in the blood are often within normal limits. In case of GIVP against the background of organic pathology of the liver, pancreas, cholelithiasis, changes in the biochemical parameters of the blood depend on the underlying disease.

X-ray methods (cholecystography, intravenous cholegraphy) provide information about the tone of the gallbladder, its concentration and contractile function, but do not provide an idea of ​​the functional state of the sphincter apparatus of the extrahepatic biliary tract.

The ultrasound research method makes it possible to identify changes in the volume of the gallbladder, the heterogeneity of the cavity of the gallbladder, its contractile function, characteristic of the gastrointestinal tract, and to exclude the organic component of damage to other organs of the hepatobiliary zone. The state of the contractile function of the gallbladder is assessed during ultrasound cholecystography, which makes it possible to study the motor-evacuation function of the gallbladder in dynamics from the moment of taking a choleretic breakfast until the gallbladder reaches its original volume.

Duodenal intubation allows us to judge the tone and motility of the gallbladder, the sphincter of the abdominal cavity and the sphincter of Lutkens. The bacteriological composition of bile can be determined. Hepatobiliscintigraphy allows you to assess the functional state of the gallbladder using the following parameters: image intensity of the gallbladder, its size and position; speed and time of onset of radiopharmaceutical accumulation in the gallbladder; time and nature of excretion of the radiopharmaceutical into the duodenum. The factor of radiation exposure, the impossibility of conducting dynamic research due to this, and the element of invasiveness limit the diagnostic capabilities of the method. It is not advisable to conduct invasive studies in patients with rare episodes of pain that are not accompanied by increased aminotransferase activity and biochemical signs of cholestasis.

Treatment

The general principle of treatment for biliary diarrhea is to normalize the neurohumoral regulatory mechanisms of bile secretion and correct dysfunction of the autonomic nervous system.

To eliminate neurotic disorders, sedatives are used, especially for hyperkinetic forms of dyskinesia. Thus, Bellataminal, in addition to the sedative effect (ergot alkaloids), affects the tone of smooth muscles. It is possible to use herbal preparations (valerian root).

Diet therapy still plays an important role in the treatment of diarrhea. The following goals are pursued:

• exclusion of products that contribute to the exacerbation of existing chronic diseases or provoke a painful attack; • regulating effect on bile secretion, reducing the lithogenic properties of bile; • stimulation of metabolic processes in the liver, aimed at improving bile formation processes, preventing the development or progression of fatty degeneration. • In addition, split meals at the same hours are a good stimulator of bile secretion.

With the hyperkinetic type of dysfunction, foods that stimulate contractions of the gallbladder should be sharply limited - animal fats, vegetable oils, rich meat, fish, and mushroom broths.

With hypotension of the gallbladder, patients usually tolerate weak meat broths, fish soup, cream, sour cream, vegetable oils, and soft-boiled eggs well. Vegetable oil is prescribed one teaspoon 2-3 times a day half an hour before meals for 2-3 weeks. To normalize stool, dishes that promote bowel movement are also recommended (bran, carrots, pumpkin, zucchini, greens, watermelons, melons, prunes, dried apricots).

Medicinal correction of varicose veins

Therapy is carried out in accordance with the nature of the damage to the biliary tract.

Among the drugs that affect bile formation and bile excretion, choleretic agents play a special role. According to their mechanism of action, they are divided into choleretics (increase the formation of bile) and cholekinetics (promote the release of bile from the gallbladder into the intestinal lumen).

Choleretics include:

– drugs containing bile and bile acids (Allohol, Festal); – synthetic drugs (Nicodin, Oxafenamide); – herbal preparations. Cholekinetics include: – magnesium sulfate; - vegetable oils; – sorbitol, xelite.

The choice of drugs depends on the type of dyskinesia. For dysfunctions caused by increased tone of the sphincters of the biliary system, antispasmodics, non-selective and selective M1-cholinergic blockers are prescribed. Myotropic antispasmodics include drotaverine, mebeverine, otilonium citrate and trimebutine. Myotropic non-selective antispasmodics include drugs that affect the activation of enzymes responsible for the state of smooth muscles in the body (phosphodiesterase, guanylate cyclase) - drotaverine, papaverine, nitrates.

For hypertonic, hyperkinetic forms of JVP, the following is used:

1) tranquilizers; 2) antispasmodics; 3) anticholinergics; 4) blind duodenal intubation

For hypotonic, hypokinetic forms of JVP, therapy includes:

1) choleretics; 2) cholekinetics that do not have an antispasmodic effect; 3) tubes.

In patients with severe visceral hypersensitivity and psychogenic pain, it is advisable to use tricyclic antidepressants (for example, amitriptyline). It has been established that antidepressants and antipsychotics have an effect on psychogenic pain and can increase the threshold of visceral sensitivity. M-anticholinergics - hyoscine butyl bromide (HBB, scopolamine butyl bromide) and the synthetic enkephalin analogue trimebutine also have an effect on visceral hypersensitivity.

Enzyme replacement therapy is aimed at improving cavity digestion and is selected individually depending on the state of the acid-forming function of the stomach and the exocrine function of the pancreas. The goal of replacement therapy is to normalize the processes of digestion and absorption of proteins and fats. Enzyme preparations containing bile components are especially indicated for hypomotor dyskinesias, accompanied by a decrease in the pool of bile acids. Bile acids have a choleretic effect, increase the contractile function of the gallbladder when it is hypotensive, improve the process of fat emulsification, and enhance pancreatic secretion. In patients with hypermotor dyskinesia, the administration of these enzymes is not advisable.

Considering the possible development of microecological disorders in the small intestine (excessive bacterial growth), in the presence of microbial contamination of the small intestine, decontamination therapy is necessary. To achieve the best effect, it is advisable to use non-absorbable intestinal antibiotics (rifaximin) or intestinal antiseptics with simultaneous and/or sequential use of pre- and probiotics.

Ursodeoxycholic acid (UDCA) has been used in clinical practice for more than 35 years. The beginning of the use of UDCA is associated with the treatment of cholelithiasis, but new mechanisms of action are constantly being discovered that make it possible to expand the indications for its use, including for biliary dysfunction.

The main mechanisms of action of UDCA:

1) anticholestatic: UDCA suppresses the secretion of toxic bile acids into bile, their absorption in the ileum and thereby promotes their excretion from the body; 2) cytoprotective: due to the presence of hydrophilicity, UDCA improves the fluidity of the phospholipid bilayer of the hepatocyte membrane, restores the structure of cells and protects them from damage; 3) hypocholesterolemic: decreased synthesis of cholesterol in the liver, decreased secretion into bile and absorption in the intestine; 4) litholytic: reducing the lithogenicity of bile due to the formation of liquid crystals with cholesterol molecules, preventing the formation and dissolution of gallstones; 5) immunomodulatory: under the influence of UDCA, the synthesis of immunocompetent IgM is reduced, the expression of histocompatibility antigens on hepatocytes and cholangiocytes is reduced, which, in turn, prevents the activation of cytotoxic T-lymphocytes, and also reduces the production of autoantibodies and helps reduce immunopathological reactions; 6) anti-apoptotic: by reducing the concentration of ionized Ca in cells, the release of cytochrome C from mitochondria is blocked, which, in turn, prevents activation of caspases and, accordingly, apoptosis of cholangiocytes.

In the presence of chronic biliary insufficiency in various pathologies of the hepatobiliary zone, including functional disorders, replacement therapy with UDCA drugs is necessary. The use of UDCA in an average daily dose of 10–15 mg/kg body weight effectively reduces the degree of biliary insufficiency and the severity of dyscholia. The dose and duration of treatment with UDCA are determined by the degree of biliary insufficiency and the dynamics of changes in the cholate-cholesterol coefficient during therapy. For biliary insufficiency of stage I, UDCA is prescribed at a dose of 7–10 mg/kg for 1–2 months; for II – 10–15 mg/kg for at least 3 months; at III – 15 mg/kg or more. After relieving biliary insufficiency and restoring the biochemical composition of bile, the dose of UDCA drugs is gradually reduced over 3 months and then discontinued. Against the background of ursotherapy, choleresis and cholekinesis also increase, the bactericidal properties of bile increase, and digestion processes improve.

Currently, a domestic representative of UDCA, the drug Ursodez, has appeared in the arsenal of a general practitioner. In 2009, studies were conducted on the relative bioavailability and bioequivalence of the drugs Ursodez® and Ursofalk®. The main pharmacokinetic parameters of these drugs did not differ statistically significantly. Based on the results of the study, it was concluded that these drugs are bioequivalent. The UDCA substance for the drug Ursodez is produced in Italy. And only then the finished dosage form is manufactured in Russia by Severnaya Zvezda CJSC, and all production is certified according to GMP standards.

A wide list of indications for use has been registered for the drug Ursodez, affecting various pathological conditions of the hepato-biliary system. In addition to the previously approved list, including the dissolution of cholesterol gallstones, biliary reflux gastritis, primary biliary cirrhosis in the absence of signs of decompensation (symptomatic treatment), new indications have been added. These include:

• chronic hepatitis of various origins; • primary sclerosing cholangitis; • cystic fibrosis (cystic fibrosis), • non-alcoholic steatohepatitis; • alcoholic liver disease; • biliary dyskinesia.

This spectrum allows Ursodez to be widely used by doctors of various specialties on an outpatient basis and in a hospital.

After registration in our country, a number of studies were conducted to evaluate the clinical effectiveness of Ursodez for various gastrointestinal diseases. Thus, on the basis of the Volgograd State Medical University, the effectiveness of Ursodez® was studied in the treatment of patients with chronic hepatitis B (CHB) and C (CHC) with weak and moderate degrees of activity. The results showed that the inclusion of Ursodez® in the general complex of therapy for CHB and CHC significantly improved cholestatic disorders in patients and had a hepatoprotective effect, which had a positive effect on the clinical course of the disease and the length of hospitalization of patients. And the appointment of Ursodez® in the treatment regimen for RFGERD, carried out as part of a study at Samara Medical University, made it possible to achieve stable clinical and endoscopic remission in the vast majority of patients with manifestations of refractory to PPI treatment.

In conclusion, I would like to note that a correct assessment of clinical symptoms using modern diagnostic methods and the further prescription of complex therapy, depending on the type of dyskinesia and concomitant pathology, helps prevent the further development of pathological processes in the digestive organs. Due to the versatility of their action, pathogenetic validity and evidence base, ursodeoxycholic acid preparations play an important role in the complex of therapeutic measures, and the introduction into everyday practice of new domestic preparations of this group of medicines, such as the drug Ursodez, which are clinically effective and have an optimal price-quality ratio, helps to increase patients' adherence to therapy and significantly improve the patient's quality of life.

Literature

1. Bystrovskaya E.V. Endoscopic ultrasonography in the diagnosis of choledocholithiasis. Author's abstract. ...cand. honey. Sci. 2003. 2. Blyuger A.F., Novitsky I.N. Practical hepatology. Riga: Zvaigzne, 1984. 3. Diseases of the liver and biliary tract. Guide for doctors. Ed. V.T. Ivashkina. M.: Publishing house. House "M-Vesti", 2005. 4. Maev I.V., Samsonov A.P., Salova L.M. and others. Diagnosis and treatment of biliary tract diseases. Educational allowance. M.: GOUVUNMTs Ministry of Health of the Russian Federation, 2003: p. 96. 5. Maev I.V., Samsonov A.A., Kucheryavyi Yu.A. Diseases of the biliary tract: diagnosis and treatment. Educational allowance. M.: GOUVUNMTs Ministry of Health of the Russian Federation. 2010; With. 54–9. 6. Minushkin O.N. Dysfunctional disorders of the biliary tract (pathophysiology, diagnosis and treatment approaches). M., 2002. p. 16. 7. Vasiliev Yu.V., Moroz I.A. Selected chapters of clinical gastroenterology. M.: Anaharsis, 2005. 8. . Vikhrova T.V. Biliary sludge and its clinical significance. dis. ...cand. honey. Sci. M., 2003. 9. Gastroenterology and hepatology: diagnosis and treatment. Guide for doctors. Ed. A.V.Kalinina, A.I.Khazanova. M.: Publishing house. Miklosh, 2007. 10. Grigoriev P.A., Soluyanova I.P., Yakovenko A.V. Gallstone disease and consequences of cholecystectomy: diagnosis, treatment and prevention. Treatment doctor. 2002; 6:26–32. 11. Zvenigorodskaya L.A., Ovsyannikova O.N., Samsonova N.G. The use of Gepabene in the treatment of gallbladder cholesterosis and steatohepatitis in patients with metabolic syndrome. Difficult patient. 2007; 6–7: 5–9. 12. Ivanchenkova R.A. Chronic diseases of the biliary tract. M.: Atmosphere, 2006. 13. Ilchenko A.A. Dysfunctions of the biliary tract and their drug correction. Wedge. perspective gastroenterol., hepatol. 2002; 5:25–9. 14. Ilchenko A.A. Cholelithiasis. M.: Anaharsis, 2004. 15. Ilchenko A.A. Pharmacotherapy for diseases of the gallbladder and biliary tract. M.: MIA, 2010. 16. Ilchenko A.A. Diseases of the gallbladder and biliary tract. Guide for doctors. M.: MIA, 2011. 17. Orlova Yu.N. Gallbladder cholesterosis. 18. Clinical sonographic study. dis. ...cand. honey. Sci. M., 2004. 19. Sherlock Sh., Dooley DLzh. Diseases of the liver and biliary tract. Per. from English M.: GEOTAR-Medicine, 1999.

About hydrocholeretics

Some table medicinal mineral waters are called hydrocholeretics. They simply reduce the thickness and viscosity of bile, and make it more fluid. Unlike ordinary water, when mineral water is absorbed in the intestinal lumen and penetrates into the portal bloodstream, it is absorbed by liver cells first and increases the pressure in the bile ducts by osmosis.

Essentuki-17, Essentuki-4, Naftusya, Slavyanovskaya and Smirnovskaya mineral water work great. In addition to increasing pressure in the bile ducts, the reabsorption of water and electrolytes in the gallbladder and biliary tract is also significantly reduced, which also reduces the potential for lithogenicity, or the possibility of gallstone formation.

Also, the effect of mineral water on the bile ducts depends on the so-called sulfate anion, or sulfuric acid residue, SO4, which is usually combined with sodium and magnesium cations. These sulfuric acid salts - magnesium and sodium sulfate - have a pronounced choleretic effect. Many metal cations do useful work. Thus, calcium (Ca2+) forms a complex compound with bile acids, which significantly reduces the likelihood of poorly soluble bile sediment, which contributes to the subsequent formation of stones. Such mineral salts make bile more fluid, and in its colloidal state it becomes more stable. Mineral waters should be consumed 30 minutes before meals, preferably warm and with gas released, if any.

List of choleretic drugs cholekinetics

These medications help reduce the bile ducts. These include:

Magnesium sulfate powder

The preparation contains magnesium in its pure form. Analogues are other drugs containing magnesium.

For treatment, you need to dissolve 1 sachet in a liter of water and take this solution one tablespoon 3 times a day.

Magnesium is not used for allergic reactions, as well as against the background of inflammatory processes in the intestines. Also, magnesium is not prescribed for cholelithiasis, during pregnancy and in case of obstruction of the bile outflow tract.

The advantages of the drug include its low cost, which is 30 rubles, as well as ease of use.

The downside of the drug is that it cannot be taken if you have gallstones. Therefore, without undergoing a medical examination, the use of the drug is unacceptable.

Sorbitol

The main active ingredient is sorbitol. The drug has no analogues. To provide a therapeutic effect, a tablespoon of Sorbitol is dissolved in 250 ml of warm water and taken orally. Then you need to place a warm heating pad under the right hypochondrium and lie in this position for half an hour.

You should not take the drug if you have ascites, irritable bowel syndrome, or inflammation of this organ.

The advantages of the drug include its rapid therapeutic effect, as well as low cost. For 350 g of powder you will have to pay no more than 90 rubles.

The disadvantage of the drug is that it can cause flatulence and diarrhea. If you take Sorbitol in large quantities, it carries a risk of developing diabetic retinopathy and neuropathy. Moreover, it is contraindicated in obese patients.

Choleretic-kinetics: stimulants of bile removal

Cholekinetics, which stimulate bile drainage, can work in two different ways, and choleretic kinetic drugs are divided into two types of opposite action. If the bladder is hypotonic, its smooth muscles are flabby and weak, then it is necessary to increase its tone and enhance its ability to contract. At the same time, these drugs reduce tonic tension and increase the lumen of the structures of the common bile duct. They simply irritate the intestines by activating a cascade of gastrointestinal hormones (cholecystokinin). An example of such a choleretic drug would be magnesium sulfate, or magnesium.

These drugs are prescribed mainly for hypotonic biliary dyskinesia, congestion in the gallbladder with a decrease in its tone. These drugs are indicated for gastritis with low acidity, as well as cholekinetics, which contract the gallbladder, are indicated during duodenal intubation in a healthy person.

The second group of drugs includes antispasmodics, which relax the excessively contracted gallbladder, reduce its spasm, and at the same time relax the bile ducts. This allows you to improve the removal of bile, and an example of such cholekinetics is No-shpa, Papaverine, or the stronger atropine and platiphylline, which are used in medical institutions and when calling an ambulance.

These drugs are necessary for hypertensive forms of dyskinesia, in the presence of stones in the gall bladder and bile ducts. They are able to reduce pain, which often occurs against the background of spasm of the biliary tract and in the presence of cholelithiasis.

Let's look at the most popular and effective cholekinetics, which are sold in pharmacies and included in the rating.

Magnesium sulfate (magnesium)

Rating: 4.9

Magnesia is the simplest and most accessible choleretic and laxative. This colorless powder, easily soluble in water, has an intense bitter-salty taste, and magnesia is unpleasant to drink. But in addition to the choleretic effect, it also has an anticonvulsant effect, helps normalize heart rhythm, has a hypotensive effect and can fight constipation. Magnesia is used for cholecystitis and cholangitis, to obtain a cystic portion of bile during duodenal intubation, for hypotonic dyskinesia of the gallbladder, and to cleanse the intestines. It is necessary to apply magnesium by dissolving one packet (25 g) in one glass of warm water and drinking between meals 3 times a day, before meals. In this case, after an average of one or two hours, the drug will have the necessary choleretic effect, which will last for 4 or even 6 hours. Usually, after this, a certain loosening of the stool occurs, since the osmotically active magnesium solution will promote an intensive influx of water into the intestinal lumen.

The Moscow Pharmaceutical Factory produces magnesium sulfate, and one 20 g package costs an average of 38 rubles.

Advantages and disadvantages

The advantages of magnesia include its universal availability and low cost, the onset of a quick effect, and a simple and understandable mode of application. But this drug also has contraindications. You should not take magnesia if the patient has loose stools, symptoms of renal failure, low blood pressure and slow heart rate (bradycardia). Magnesia is contraindicated in patients with various cardiac arrhythmias, since it can significantly worsen their condition, especially in the case of complete atrioventricular block, when impulses from the atria are disconnected from ventricular contractions.

Sorbitol (Sorbitol)

Rating: 4.8

Sorbitol, or more precisely, sorbitol, is a polyhydric alcohol, and in addition to being a choleretic agent, it has an osmotic and laxative effect. Sorbitol is also used in some cases to reduce the symptoms of intoxication: it removes the toxic substance into the intestinal lumen.

Sorbitol is produced in the form of a powder for oral administration, in sachets of 5 g, sometimes in powder, packaged in 200, 300, 500 g. Sorbitol is indicated for use in cases of biliary dyskinesia of the hypotonic type, in chronic hepatitis in complex therapy, tendency to constipation.

It is necessary to use sorbitol for choleretic purposes by dissolving 5 g of the drug in half a glass (100 ml) of slightly warmed water. You need to take this sweet solution 10 minutes before meals twice a day. The course of treatment is 1 month. Sorbitol is produced by the domestic company Fruit Happiness, and you can purchase the largest package weighing 500 g for an average price of 145 rubles.

Advantages and disadvantages

The advantage of sorbitol is its low cost and wide range of applications, since it can be prescribed not only for dyskinesia and cholecystitis, but also for the treatment of constipation. However, sorbitol is contraindicated in all acute conditions, with intolerance to fructose, which is part of it, and if you exceed the required amount, and make the solution either too strong or drink too much, intense diarrhea, dry mouth, nausea, and symptoms of dehydration may occur . But sorbitol can be safely used by diabetics, since it does not contain glucose.

No-spa (drotaverine)

Rating: 4.8

The most famous antispasmodic tablets No-shpa, or drotaverine hydrochloride, are produced by the Hungarian pharmaceutical company Hinoin. No-spa is a remedy that reduces spasms of smooth muscles not only of the gallbladder and bile ducts, but also of the smooth muscles of the urinary tract, therefore this drug is indicated for renal colic.

No-spa allows you to reduce severe pain in hypertensive forms of biliary dyskinesia, cholangitis, and cholecystitis. No-spa is available not only in tablets, but also in solutions, so very often it is administered intramuscularly. Only antispasmodics are indicated for pain in the abdominal cavity, in the condition of “acute abdomen”. The fact is that if you use strong painkillers, you can relieve pain and miss the condition when urgent surgery is required, for example, in acute appendicitis. Antispasmodic drugs do not have an analgesic effect, and all it can do is relax the muscles.

Therefore, if there is a focus of progressive inflammation in the abdominal cavity, for example, with the same calculous cholecystitis, then No-Spa will not help, but if the pain is caused by a spasm in the neck of the gallbladder, then the desired effect will be achieved, the spasm will be resolved, the bile will be released into the intestines, and the patient's condition will improve.

To use No-shpa in tablets it is necessary from 1 tablet of 40 mg to 6 tablets per day, that is, no more than 2 tablets three times a day, it is advisable to take it before meals, so that during the meal it manifests its effect and relaxes smooth muscles of the biliary tract. One package of No-shpa in the amount of 24 tablets costs about 130 rubles.

Advantages and disadvantages

The big advantage of No-shpa is its fairly high activity and speed. Symptoms of overdose such as arrhythmia are quite rare, but for this to happen, the patient must initially have severe heart disease. No-spa is a universal drug; it not only helps to increase the outflow of bile, but it also helps to normalize the outflow of urine, since the same smooth muscle elements exist in both the ureters and the bile ducts. Few side effects were noted. Rare symptoms include tachycardia, headache and nausea, allergic reactions. But, despite all the minor disadvantages, No-Spa is quite in demand, and has long existed in every home medicine cabinet as a remedy of choice for abdominal pain, since only taking antispasmodics will avoid serious complications if surgical intervention is necessary.

Indications for taking choleretic drugs

To understand which drug to choose and take, you need to understand the direction of bile movement throughout the body.

Her path goes like this:

• Bile is produced in liver cells, after which it enters the intrahepatic bile ducts.
• Through the intrahepatic pathways, bile enters the hepatic ducts (left and right). From them it flows into the common hepatic duct, which is represented by a tube containing a minimal amount of muscle.
• From this duct, bile enters the gallbladder through another duct, which is unable to contract because it does not have a muscle base. Bile needs some kind of force to flow into its storage reservoir (gallbladder). It is a difference in pressure: the pressure of the liver when it was producing bile, against the resistance of the sphincter of Oddi. This sphincter is represented by the round muscle, which is a continuation of the common hepatic duct. It leads to the duodenum. The sphincter of Oddi can be compared to a faucet: if it is closed, the bile enters the cystic duct, straightens the muscleless folds and penetrates the gallbladder, where it begins to heat up.
• When the gallbladder fills with bile, pressure increases in it. At the same time, it decreases in the hepatic tract. When food enters the human stomach, it begins to produce pepsin, which signals the sphincter of Oddi to open. Due to pressure changes, bile enters the duodenum, having the required concentration, which it acquired in the gallbladder, getting rid of excess fluid.
• When the pressure in the gallbladder increases to 250-300 mm of water, the organ begins to contract on its own, which forces the sphincter of Oddi to open.
• The common bile duct is deprived of the ability to contract, since it has practically no muscle fibers.

Knowing what path bile takes in the human body, you can understand the issue of choosing a medicine.

Indication No. 1: biliary dyskinesia

Dyskinesia means that bile moves with disturbances, but which ones exactly need to be sorted out.

Dyskinesia depends on several parameters:

• Tone of the biliary tract.

  If it is normal, then no medications need to be taken. If the tone is increased, then the bile will exit the biliary tract too quickly, which will lead to its reflux into the stomach. In this case, it is necessary to take drugs from the group of cholespasmolytics. When the tone of the biliary tract is too low, bile will move through it slowly. To raise tone, cholekinetic drugs are used.

• The rate of contraction of the biliary tract.

  If they contract at a normal rate, then no treatment is required. At a high rate of contraction, bile does not have time to gain the concentration it needs. To correct this condition, you will need to take antispasmodics. If the bile ducts, on the contrary, contract too slowly, then the bile will stagnate. In this case, a person needs to take either choleretics (more bile will be formed) or cholekinetics, which accelerate its movement.

So, a refined diagnosis of “biliary dyskinesia” may be as follows:

• Hypertensive hyperkinetic dyskinesia. Most often, synthetic cholespasmolytics are prescribed.
• Hypertensive normokinetic dyskinesia. In this case, the patient is prescribed cholespasmolytics of plant origin, which do not reduce the contractility of the biliary tract.
• Hypertensive hypokinetic dyskinesia. In this case, bile cannot pass through the pathways due to their spasm, so it needs to be eliminated. Cholekinetics are prescribed in combination with an antispasmodic.
• Hypotonic hypokinetic dyskinesia. To get rid of pathology, cholekinetics and choleretics are needed.
• Hypotonic normokinetic dyskinesia. To eliminate this disorder, you need to take a choleretic drug.

If you take medications without understanding what is happening with bile in the body, then serious health problems can arise. Most people take choleretics, which stimulate bile production. However, they do not think about the consequences. After all, we cannot exclude the possibility of a kink in the gallbladder or hypokinetic dyskinesia. An excess of bile will cause the gallbladder to contract very sharply, which causes severe pain. This pain is known as biliary colic.

In addition, a person can take cholespasmolytics. This will lead to stagnation of bile, in which salts combined with cholesterol will begin to accumulate. Then they will precipitate, which will provoke the formation of stones. It is also impossible to exclude infection of the bile with further development of cholecystitis.

Indication No. 2: stagnation of bile

Drugs that are prescribed to eliminate stagnation belong to the group of cholekinetics and choleretics. However, before taking them, it is necessary to undergo an ultrasound to ensure that there are no stones in the bile ducts. When such deposits are absent, or their diameter does not exceed 3 mm, the patient is prescribed drugs based on bile acids.

When bile stagnates in the liver and the patient develops itchy skin, and the dermis itself acquires a yellow tint, it is necessary to take choleretic drugs in combination with other medications. Often, treatment at home is impractical, and the patient is hospitalized.

Indication No. 3: inflection of the gallbladder

When the gallbladder is bent, dyskinesia always develops. It can be hypokinetic and hypermotor. To eliminate this disorder, cholespasmolytics, cholekinetics, and also agents containing bile acids will be required. If the pathology is not in an acute stage, then the choice should be made on herbal medicines.

It also cannot be excluded that the inflection of the gallbladder is characterized by hypomotor and hypokinetic dyskinesia. In this case, the patient is prescribed drugs from the group of cholekinetics. Although sometimes they are replaced by taking choleretics.

Indication No. 4: cholecystitis

Cholecystitis is an inflammation of the gallbladder itself.

To eliminate it, the following medications are used:

• Choleretics, which dilute bile, freeing it from infection. In this way, it seems to be possible to refresh it.
• Cholespasmolytics, which reduce the intensity of pain and relieve spasm from the muscle wall of the gallbladder.
• Cholelitogenic drugs, which are used to prevent the formation of gallstones.

To eliminate inflammation, antibacterial drugs are required. Moreover, the use of antibiotics from different groups (2 drugs) is recommended.

Indication No. 4: pancreatitis

Inflammation of the pancreas, which is called pancreatitis, leads to the production of enzymatic secretions in large volumes. Bile stimulates the production of these enzymes, so in order not to aggravate the situation, you need to make sure that it is released little by little. You should also exclude the possibility of an unexpected release of bile. For this purpose, cholespasmolytics are prescribed. Their use is indicated for both chronic and acute pancreatitis. To prevent stones from forming in the gallbladder during this period (stagnation cannot be avoided), you must simultaneously take medications to dissolve them.

It is important to understand that inflammation of the pancreas is a serious pathology that requires medical supervision.

Indication No. 5: removal of the gallbladder

After the gallbladder is removed from the body, bile loses the place where it could reach the concentration it needs. As a result, it enters the duodenum in a diluted form. However, stones can form even in such low-concentration liquid. Therefore, all patients without exception are prescribed cholelitogenic drugs.

It is strictly forbidden to take choleretics after surgery, as this will lead to an increase in bile production.

For a period of 3 months (after cholecystectomy), patients are prescribed antispasmodics. The fact is that when the gallbladder was still present in the body, it worked in tandem with the sphincter of Oddi. The bladder contracted and the sphincter relaxed. After the organ is removed, the sphincter of Oddi is not able to perform its work as consistently as before. Therefore, his muscles simply go into spasm. To relieve this spasm, you need to take cholespasmolytics. If this is not done, the spasm will turn into stenosis and the person will again end up on the surgical table.

Hypertonicity of the sphincter of Oddi requires the use of cholekinetics. In parallel, the patient should receive antibiotics, anti-inflammatory drugs and hepatoprotectors.

Choleretic preparations of herbal origin

Plant-based choleretics

Cholekinetics of plant origin

Cholekinetics of plant origin include preparations that contain any vegetable oils, but olive, sunflower and cumin oils have the greatest effect. This group includes: fennel (fruits), calamus (roots and rhizomes), barberry leaves, caraway seeds (fruits).

The drug Berberis-homaccord can also be classified as a herbal cholekinetic, as it has multiple effects, including normalizing the functioning of the bile ducts.

Cholespasmolytics of plant origin

The group of plant cholespasmolytics includes valerian, Cholagol, as well as herbs such as calendula, St. John's wort, tansy, arnica, turmeric root.

Choleretic drugs for the treatment of children

In childhood, the following choleretic drugs can be used:

• From 3 years of age Holosas is prescribed.
• From six months you can use Papaverine and Atropine, but under strict medical supervision.
• From the age of 6 years, Hofitol, Flamin and Eufillin are prescribed.
• From 7 years old you can take Urolesan.
• Duspatalin is allowed to be taken from 10 years of age.

However, before starting treatment, consultation with a specialist is required.