Etiology and clinical aspects of gallbladder stones
Gallbladder stones are common in hepatobiliary surgery, mainly in adults and in women, especially in menstruating women and those taking birth control pills. The causes of gallbladder stones are complex, but it is believed that the cholesterol in the bile is supersaturated due to changes in the composition and physicochemical properties of the bile, which leads to easy precipitation and crystallization. It is also believed that the presence of a nucleating factor in the bile, which secretes a large amount of mucus glycoprotein, is related to the formation of stones. In addition, reduced contractility of the gallbladder and stagnation of bile in the gallbladder (frequent vegetarian diet, fasting or skipping breakfast, etc.) also facilitate stone formation.
Major symptoms
Discomfort depends on the size and location of the stones, as well as on the presence of obstruction and inflammation. About half of the patients with gallbladder stones are asymptomatic for life and are referred to as occult stones. Larger gallbladder stones may cause symptoms of indigestion such as fullness in the upper or right side of the abdomen, belching and aversion to fatty foods. Smaller stones may cause biliary colic and acute cholecystitis when they block the gallbladder duct after a full meal, eating fatty food or lying down at night. With the contraction of the gallbladder, smaller stones may enter the common bile duct through the cystic duct and cause obstructive jaundice, cholangitis or pancreatitis, and then some stones may be discharged into the duodenum through the bile duct.
Diagnosis
The diagnosis of gallbladder stones with a history of acute attacks is not difficult based on clinical manifestations. If there is no history of acute attack, it is necessary to rely on auxiliary examinations such as ultrasound, which can show the intense light mass in the gallbladder and the acoustic shadow behind it, and the correct diagnosis rate can be more than 95%.
Treatment
1. Surgical treatment
Surgical resection is the main surgical modality for the treatment of gallbladder stones and cholecystitis, which can be divided into laparoscopic cholecystectomy and open cholecystectomy. The clinical application of the former is more popular because it is less traumatic and less painful, but open cholecystectomy is still necessary to provide safe cholecystectomy when biliary variants are found during laparoscopy or when the surrounding structures are unclear due to bleeding or gallbladder inflammation.
Recently, some studies have shown that lithogenic bile from the liver forms gallbladder stones, therefore, since 2007, minimally invasive cholecystectomy has been carried out in China to surgically remove stones from the gallbladder while preserving the gallbladder. Although preserving the gallbladder as an organ is easily accepted by patients, the functional condition of the preserved gallbladder and the recurrence of stones are still subject to further clinical follow-up observation studies, and therefore are not widely However, the functional status of the preserved gallbladder and the recurrence of stones are still subject to further clinical follow-up studies and are therefore not widely accepted by surgeons.
Cholecystectomy is usually recommended in the following cases.
1. gallbladder-filled stones;
2. symptomatic gallbladder stones with recurrent symptoms affecting the quality of life;
3. gallbladder stones with gallbladder atrophy;
4. gallbladder stones with a history of pancreatitis attacks;
5. Gallbladder neck stones with gallbladder enlargement;
6. gallbladder stones with significant thickening of the gallbladder wall;
7. gallbladder stones >2.5 cm or more without a history of cholecystitis
8. gallbladder stones suspected to be gallbladder cancer.
The decision of whether to operate or not will depend on the patient’s specific situation. If an elderly patient has other serious cardiopulmonary disorders and the risk of surgery is high, the risk-benefit ratio of surgical treatment should be carefully analyzed, so as not to take a huge risk to remove gallbladder stones and cholecystitis that are not yet life-threatening.
2. Lithotripsy treatment
The main mechanism of gallbladder stone formation is the alteration of the physicochemical composition of bile, the narrowing of the bile acid pool and the increase of cholesterol concentration. Goose deoxycholic acid (CDCA) and ursodeoxycholic acid desaturate the bile by reducing the secretion of bile cholesterol, while unsaturated bile has the effect of dissolving cholesterol, so that the cholesterol molecules on the surface of gallstones are continuously dissolved and the size of gallstones is gradually reduced to complete dissolution. However, this drug has certain toxic reactions to the liver, such as elevated glutamate transaminase, and even stimulates the colon to cause diarrhea. At present, the main litholytic drugs are goose deoxycholic acid and its derivative ursodeoxycholic acid. Indications for treatment: ① gallbladder stones less than 2 cm in diameter; ② gallbladder stones with little calcium that can be transmitted by X-ray; ③ gallbladder duct patency, i.e. a functional gallbladder can be shown on oral cholecystography; ④ the patient’s liver function is normal; ⑤ there is no obvious history of chronic diarrhea. The therapeutic dose is 15 mg/g per day for 6 to 24 months. The efficiency of stone dissolution is generally 30-70%. Ultrasound or oral cholecystography is performed once every six months during the treatment period to understand the dissolution of stones. Because lithotripsy is expensive and has certain toxic side effects, and often requires lifelong medication (3 months after discontinuation, cholesterol in bile will become supersaturated again, and stones are easy to recur, with a 3-year recurrence rate of up to 25%), the clinical application of lithotripsy is not accepted by the majority of surgeons. It has also been reported that metronidazole has some litholytic effect, and phenobarbital in combination with goose deoxycholic acid can increase the litholytic effect. As early as 1985, the use of percutaneous hepatic puncture of the gallbladder cannula to inject glycerol monolipid octanoate or methyl tert-butyl ether was reported for direct intracellular lithotripsy.
3. Extracorporeal shock wave lithotripsy
In 1984, Lauerbwch used extracorporeal shock wave for the treatment of cholelithiasis (extracorporeal shock
wave-lithotripsy, ESWL for short). The stones in the gallbladder can be crushed after about 1 hour of vibration wave treatment, usually using an impact frequency of 1.25-2.5 times/sec and 100% of the treatment power. Ultrasound can be applied to locate and monitor the stone crushing process.
In order to improve the disappearance rate after stone crushing, ursodeoxycholic acid (UDCA) 8mg/kg/d is often taken before and after the shock wave to achieve the synergistic effect of stone crushing and lithotripsy. UDCA is usually continued for more than six months to consolidate the efficacy of the treatment after the stones disappear. Because of the potential damage of ESWL to the bile duct wall and surrounding organs, the clinical application of this therapy has tended to be eliminated.
Diet for patients with gallbladder stones
1.No alcohol and alcoholic beverages;
2.Eating regularly, breakfast should be good;
3, low cholesterol diet. Excessive cholesterol intake can increase the metabolic and cleaning burden of liver and gallbladder, and cause excess cholesterol to crystallize, accumulate and precipitate in the gallbladder wall, thus forming stones. Therefore, cholesterol intake should be reduced, avoid eating high cholesterol foods such as: eggs (especially egg yolk), fatty meat, seafood, fish without scales, animal offal, etc.
4.It is advisable to eat a variety of fresh fruits and vegetables, low-fat and low-cholesterol foods such as: mushrooms, fungus, celery, bean sprouts, kelp, lotus root, fish, rabbit, chicken, fresh beans, etc.
5.It is advisable to eat more dry beans and their products.
6.It is advisable to use vegetable oil, not animal oil.
7, eat less chili, raw garlic and other stimulating food or spicy food
8.It is advisable to use cooking methods of boiling, steaming, braising, stir-frying, mixing, blanching and stewing, not frying, deep-frying, baking and smoking.
9, usually drink water, pinch a little hawthorn, sea buckthorn, ginkgo, gibberellic acid grass into a glass of water when drinking tea. Hawthorn 10 grams, hang chrysanthemum 10 grams, cassia seeds 15 grams, decoction of soup for tea or drinking green tea.
Potential risks of gallbladder stones.
1. Recurrent attacks of acute cholecystitis, which affect the quality of life;
2. Gallbladder stones migrate to the common bile duct via the gallbladder duct causing bile duct blockage, leading to cholangitis and pancreatitis;
3.
3. Recurrent attacks of chronic cholecystitis may lead to gallbladder carcinoma. The probability of gallbladder cancer complicating gallbladder stones is about 0.5% to 1%, and the cancer rate is high for those with a long history of disease and stones larger than 2.5 cm in diameter. Therefore, patients with gallbladder stones larger than 2 cm in diameter are usually recommended to have their gallbladder removed.
Diseases that are easily confused with gallbladder stones.
1. chronic gastritis The main symptoms are stuffy and painful upper abdomen, belching, loss of appetite and history of dyspepsia. Gastroscopy can help to clarify the diagnosis.
2. Peptic ulcer
With a history of ulcer, epigastric pain is related to the regularity of diet, while gallbladder stones and chronic cholecystitis tend to increase pain after eating, especially high-fat food. Ulcer disease often has an acute onset in the spring and fall, while gallstone chronic cholecystitis tends to develop at night. Barium meal examination and gastroscopy can be further diagnosed.
3. Neurosis
Although there is a long history of recurrent attacks, they are not related to the consumption of greasy food and are mostly associated with mood swings. There is often neurological vomiting, which occurs suddenly after eating, usually without nausea, with little vomiting and no effort, and can eat after vomiting, without affecting appetite and food intake. The disease is often accompanied by systemic neurological symptoms, and is effective with suggestive therapy.
4. Hypogastric prolapse
It can be combined with prolapse of other organs such as liver and kidney. Epigastric discomfort is aggravated after meals, and the symptoms are reduced in the lying position.
5. Renal prolapse
There are mostly symptoms such as poor nausea, vomiting and so on, mostly on the right side, but the pain in the right upper abdomen and lumbar region is aggravated when standing and walking, and colic may appear and radiate to the lower abdomen. Physical examination is performed in the prone, sitting and standing positions respectively, and the finding of right upper abdominal swelling displaced by position change is meaningful for differentiation, and renal X-ray and intravenous urography in the prone and standing positions are helpful for diagnosis.
6. Acute and chronic hepatitis manifests as dyspepsia and right upper abdominal discomfort, splenomegaly, abdominal wall varices, spider nevus and hepatic palms may appear.
7. Chronic pancreatitis
The upper abdominal pain radiates to the back of the left shoulder, and pancreatic calcification shadow or pancreatic stone can sometimes be seen on X-ray plain film; magnetic resonance cholangiopancreaticography (MRCP) and retrograde cholangiopancreatography (ERCP) are valuable in diagnosing chronic pancreatitis.
8. Gallbladder cancer is often combined with gallbladder stones. When jaundice appears, it is mostly caused by tumor infiltration of liver tissue or lymph nodes compressing the bile ducts, ultrasound and CT examination can help diagnose.
9. History of hepatitis and elevated fetoprotein can help to diagnose hepatocellular carcinoma, such as ultrasound and CT showing liver lesions can further clarify the diagnosis. If right upper abdominal pain appears in liver cancer, it is mostly in the middle and late stage.