Stone disease of the biliary system is also known as “cholelithiasis” or “gallstone disease”. It is the sum of a series of biliary stone diseases. “Gallstone disease is the result of gallbladder stones. What exactly are the dangers of gallbladder stones? In fact, this problem is not too difficult for people who study medicine to understand, but for ordinary people is a difficult problem. In my daily work, I often need to explain to patients and their families repeatedly, and I find that most of them can understand after listening. Therefore, I think it is not too difficult for most people to understand if they can use plain language or pictures to illustrate. Therefore, I would like to summarize what I said during my usual check-ups or outpatient clinics, and combine it with anatomical pictures to show you the pathogenesis of gallstone disease and treatment countermeasures to unveil this series of diseases, in order to let people understand gallstone disease and better cooperate with doctors. The purpose is to let people understand gallstone disease and to cooperate with doctors more actively. The purpose is to let people know about gallstone disease and to cooperate with doctors. It helps to communicate between doctors and patients and to avoid disputes.
First of all, we would like to briefly introduce some of the sins of gallstone disease: a series of diseases caused by gallbladder stones as the first factor in order of incidence: gallbladder stones, acute and chronic cholecystitis, gallbladder stone neck impaction, acute purulent cholecystitis, common bile duct stones, obstructive purulent cholangitis (severe cholangitis), cholangitis pancreatitis, infectious shock, sepsis. If you can read the following explanation patiently, you will be able to understand where your stones are now, how they will develop in the future, what consequences they may have, and what treatment you should choose. After knowing this, you will be able to consciously cooperate with your doctor’s treatment.
Above are two anatomical diagrams of the biliary system, and I have deliberately marked the anatomical names so that they can be easily understood when they are mentioned below. Let’s explain the natural process of stone drainage in the gallbladder: the path of stone drainage in the gallbladder is as follows: stones in the gallbladder → neck of the gallbladder → cystic duct → common bile duct → common opening of the bile duct and pancreatic duct → duodenum. This completes a complete stone evacuation process. However, it is not easy to complete such a complete stone removal process perfectly, no matter it is natural or with the help of medication. Therefore, the treatment of gallbladder stones cannot be done by extracorporeal lithotripsy or other stone removal methods, as any form of stone removal may cause stones to remain in the bile duct and cause the above mentioned “sins”.
Below is a diagram of any location in the bile duct where gallbladder stones may be lodged. Now, I will explain the corresponding diseases and treatment countermeasures when gallbladder stones are lodged in different locations in the bile duct.
(a) Gallbladder stones (shown below): are stones lodged in the gallbladder. We also call it simple gallbladder stones. Gallbladder stones are a common surgical condition. It has a prevalence of 10% in the normal population and up to 15% in middle-aged female patients. in the southwest of China, the prevalence of gallbladder stones is much higher than the national average due to climate and dietary habits. the diagnosis rate of gallbladder stones by ultrasound is 100%. Gallbladder stones and chronic cholecystitis are mutually causal. Therefore, the vast majority of stones lodged here are asymptomatic (also known as asymptomatic stones) or associated with varying degrees of chronic cholecystitis. Stones that remain in the gallbladder, even if they are not removed, will eventually cause gallbladder stones if they remain in the gallbladder for years.
Chronic cholecystitis caused by long-term gallbladder stones may lead to the development of gallbladder cancer, mostly concentrated in patients older than 70 years of age with gallbladder stones. Treatment measures should be treated separately according to the different stages of stones.
① Asymptomatic gallbladder stones in young and middle-aged people.
No therapeutic measures can be applied, only ultrasound monitoring can be done to understand the development of stones. Pay attention to regular diet and eat less fatty food. Alternatively, we can take gallbladder stone extraction surgery.
②Over 60 years old.
Because long years of gallbladder stones can lead to the occurrence of some serious diseases, as mentioned before. Combined with the fact that the body’s function decreases with age, it may cause life-threatening difficulties in surgery or post-operative recovery as a result. Therefore, it is recommended that elderly people over 60 years old with gallbladder stones should have their gallbladders removed at the right time, or perform gallbladder stone removal surgery (but this method should be carefully chosen by experienced doctors through exhaustive examination, and personally I do not recommend gallbladder stone removal).
(ii) Gallbladder stone neck impaction with acute (purulent, gangrenous) cholecystitis: the gallbladder is an organ for storing bile, and its main function is to give the body a high concentration and high quality of bile at once when the body eats to help digestion. As shown in the previous figure, if stones block the gallbladder neck causing obstruction of the bile outflow tract, the bile stored in the gallbladder cannot flow out and forms a “pool of stagnant water”. As an old saying goes, “running water does not rot, and a household pivot does not become worm-eaten”, so this “pool of stagnant water” will become stale and stink after a long time. The same obstruction of the gallbladder will form septic cholecystitis. At the same time, the gallbladder also has its own secretion function, so the obstructed gallbladder will increase in size and make the gallbladder wall thinner, and the inflammation will also cause edema and tension in the gallbladder wall, resulting in ischemic necrosis of the gallbladder wall, and finally causing gallbladder perforation and peritonitis caused by the flow of infected bile into the abdominal cavity. Therefore, the longer the obstruction lasts, the more serious problems will arise. Therefore, the sooner gallbladder stone neck impaction is done, the safer it is to have gallbladder removal.
(iii) Gallbladder stones combined with common bile duct stones: Gallbladder stones become common bile duct stones if they break through the cystic duct and enter the common bile duct. The stones that enter the common bile duct may be discharged into the duodenum, but in most cases, the stones that fall into the common bile duct stay in the common bile duct because of the contraction of the duodenal papillary sphincter at the lower end of the duct, leading to a series of problems. As a result, it may appear either as follows.
① Biliary colic due to spasm of the stones in the common bile duct as they move
The patient’s symptoms disappear with treatment or natural relief. The picture on the left is a manifestation of these two conditions. In this case, the patient is usually not too concerned, but if obstruction occurs without relief it can produce obstructive jaundice, cholangitis, etc.
②Choledocholithiasis has been discharged into the duodenum by moving
It is mainly manifested by transient biliary colic and elevated blood amylase. Most of the time, this condition can be improved by anti-inflammatory treatment through infusion. However, stones will continue to be discharged because they are still present in the gallbladder. Therefore, the stones in the gallbladder are the source, which is why it is said that “gallbladder stones are the cause of the problem”. If this “culprit” is not removed, you will never have any peace of mind. Such patients should have their gallbladder removed as soon as possible.
For patients with gallbladder stones combined with bile duct stones and in the asymptomatic phase, we strongly recommend surgery. There are two methods.
(1) open cholecystectomy + common bile duct extraction with “T” duct drainage
The stones in the gallbladder and common bile duct are resolved in a single operation. In this way, the source of the stones and the stones in the bile duct are treated at the same time. The gallstone disease is then completely cured.
(2) Laparoscopic cholecystectomy + common bile duct extraction + T-tube drainage or common bile duct stitching surgery
This procedure is currently the first choice for the treatment of gallbladder stones combined with common bile duct stones. It can solve both gallbladder stones and common bile duct stones at the same time, while using a minimally invasive procedure like laparoscopy, the patient suffers less pain and recovers quickly after surgery. In many large surgical centers, this procedure
It is a common surgical procedure in many large surgical centers, and since its introduction in 1994, we have performed about 2,000 cases of this procedure with good results.
(iii) Preoperative ERCP + laparoscopic or open cholecystectomy.
The first step: first deal with the stones in the common bile duct, using a non-operative method: enter the duodenum through the mouth with a duodenoscope and drag out the stones in the common bile duct from the opening of the duodenal biliopancreatic duct – the duodenal papilla, this method is suitable for smaller stones in the common bile duct, if the stones are larger than 1 cm, it is preferred to consider the second surgical method more secure.
Step 2: Laparoscopic cholecystectomy is performed within a week after the completion of the first step. This also achieves to deal with the source place of stones and stones in the bile duct. This is the end of the treatment.
(iv) Septic cholangitis, severe cholangitis, and cholangio-pancreatitis: As mentioned above, if the stones entering the common bile duct do not drain into the duodenum, and the stones block the lower end of the bile duct or the opening between the bile duct and the pancreatic duct, septic cholangitis, severe cholangitis, and cholangio-pancreatitis will occur. They are the most serious of general surgical diseases and have a high mortality rate. In case of infectious shock or sepsis, emergency surgery (laparoscopic or open cholecystectomy + choledochotomy with “T” duct drainage) is required, otherwise it may be life-threatening. This is especially true for the elderly.
For patients with only purulent cholangitis (with common bile duct stones) and biliary pancreatitis with stable vital signs, endoscopic duodenal papillotomy (EST or EPT), stone extraction and nasobiliary drainage can be performed in emergency situations in hospitals where available to temporarily treat stones in the common bile duct and relieve purulent cholangitis and biliary pancreatitis through nasobiliary drainage. Laparoscopic cholecystectomy will be performed after the above conditions have improved. Of course, laparoscopic or open cholecystectomy + common bile duct extraction with “T” duct drainage can be performed.
In addition, some people have the misconception that after cholecystectomy, there is no place for stones to grow, so they all grow into the bile duct. It is true that there are a few cases of stones forming in the bile ducts several years after gallbladder removal. But these are two kinds of diseases. We call it secondary bile duct stones after stones from the gallbladder have entered the bile duct. This is the case in all the cases we are talking about today. Stones formed in the bile duct are called primary bile duct stones, and the composition of the stones formed in both is different. In other words, the stones in the bile ducts will continue to grow regardless of the presence of the gallbladder. It is not related to the removal of the gallbladder. It is not possible to refuse surgery because of this wrong opinion. This is an ignorant and foolish approach that does not believe in medicine. It should be reminded that the above mentioned methods of treating stones in different areas have strict indications and some methods need to be implemented in hospitals with certain conditions. And the cost of different methods varies greatly. The purpose of this article is to let the internet users know some basic knowledge about gallstones, and if there are such patients undergoing treatment, they must listen to their local doctors. What’s more, you should not use this article to direct your doctor. Because conditions vary from place to place, no matter what surgical method is used, as long as it can solve the problem, it is the right one.
With the above explanation, I think we can all understand that stones in the gallbladder have to go through a thousand difficulties to be discharged from the gallbladder into the duodenum, in which many diseases full of dangers are waiting. This is how the gallstone series of diseases occurs. Therefore, any lithotripsy treatment should not be implemented lightly without surgical procedures as a guarantee. Our treatment is based on prevention and early management of gallbladder stones, which can provide twice the result with half the effort. Through this article, I think patients with stone disease can have a clear understanding of their current situation and what treatment should be taken, but please go to your local hospital for consultation with a specialist for your specific condition. Some of the contents of this article are taken from the internet and are used for scientific purposes only, so I would like to express my gratitude to the quoted authors.