There are two types of bile duct stones: primary and secondary. Primary bile duct stones are stones that originate in the bile duct system (including intrahepatic bile ducts). The nature of the stones is mostly pigmented mixed stones containing high amounts of calcium bilirubin, and stones must be present in the gallbladder. In our country, most of the bile duct stones belong to this category. Secondary bile duct stones are stones formed when stones in the gallbladder enter the common bile duct through the enlarged cystic duct. The shape and nature of the stones are mostly the same as those in the gallbladder, and most of them are polyhedral cholesterol mixed stones. Stones secondary to biliary tract infection have an outer layer with bilirubin calcium deposits.
Intrahepatic bile duct stones are a type of bile duct stone that is found in each branching bile duct above the confluence of the right and left hepatic ducts. It can exist alone or in combination with extrahepatic bile duct stones. It is usually a bilirubin stone. Intrahepatic bile duct stones are often combined with extrahepatic bile duct stones. Intrahepatic bile duct stones are not only common, but more importantly, the resulting serious complications are an important cause of death from benign biliary disease.
The etiology of intrahepatic bile duct stones is complex and is associated with intrahepatic infection, biliary stasis, and biliary ascariasis. Intrahepatic bile duct stones may be diffusely present in the intrahepatic biliary system or may occur in the bile ducts of a particular lobe or segment of the liver, and are significantly more common in the left lobe than in the right lobe. Clinically, the symptoms of patients with intrahepatic choledocholithiasis are usually atypical. In the interval of the disease, they are mostly asymptomatic or show only mild discomfort in the right upper abdomen; in the acute phase, they may show symptoms of acute purulent cholangitis (jaundice, chills, fever, etc.). The diagnosis of intrahepatic bile duct stones is complicated. In addition to the clinical manifestations of the patient, ultrasound and percutaneous hepatic percutaneous cholangiography (PTC) can be performed to show the distribution of intrahepatic bile duct stones and the narrowing and dilatation of the hepatic bile ducts. In addition, CT examination is also important for the diagnosis of intrahepatic bile duct stones, especially for those complicated by biliary cirrhosis and cancer. Intrahepatic bile duct stones are often complicated by bile duct obstruction, which can easily induce local infection and secondary bile duct stenosis, making it difficult for the stones to drain on their own and prolonging the disease.
Epidemiology
The disease is found in the Far East and Southeast Asia, including China, Japan, Korea, the Philippines, Thailand, Indonesia and Malaysia. The incidence is higher in coastal areas, southwest China and Hong Kong and Taiwan. The incidence of intrahepatic bile duct stones in China is about 16.1%.
Pathophysiology
The right and left hepatic ducts converge to form the common hepatic duct. The right intrahepatic bile duct is divided into the right anterior lobe hepatic duct and the right posterior lobe hepatic duct; the left intrahepatic bile duct is divided into the left inner lobe hepatic duct and the left outer lobe hepatic duct. Intrahepatic bile duct stones tend to occur at the beginning of the left hepatic duct, where the duct is narrowed with luminal dilatation and accumulation of stones. They are also found in the opening of the right hepatic duct where the right anterior and posterior hepatic ducts converge to form the right hepatic duct, where bile duct stones accumulate. Normal bile ducts are 0.7-1.0 cm in diameter at PTC and ERCP, and duct diameter of 1.0 cm is considered as biliary obstruction with etiology of bile duct stones, tumors, and benign stenosis of papillae. Mild stenosis of intrahepatic bile duct means the maximum diameter of bile duct exceeds the minimum diameter by less than one times. Severe stenosis means that the maximum diameter of the bile duct is more than one times the minimum diameter.
Intrahepatic bile duct stones are almost exclusively calcium bilirubin stones, consisting of bilirubin, cholesterol, fatty acids and calcium. Intrahepatic bile duct stones may be bilateral or may be limited to the left or right liver, with the left intrahepatic bile duct stone being more common than the right.
Intrahepatic bile duct stones coexist with narrowing and dilatation of the intrahepatic bile ducts, so there is retention of bile. Stenosis can be seen on both sides of the hepatic duct, more often on the left side, and also at the confluence of the left and right hepatic ducts in the hepatic portal. In a few cases, only intrahepatic bile duct stones are present without bile duct stenosis.
Pathogenesis
The pathogenesis of intrahepatic bile duct stones is related to bacterial infection of the biliary tract, parasitic infection and bile retention. Infection is the primary factor leading to stone formation, and the common causes of infection are biliary parasitic infections and recurrent cholangitis. B-glucuronidase produced during infection by E. coli spp. and some anaerobic bacteria and endogenous glucuronidase produced during biliary tract infection can cause conjugated bilirubin to hydrolyze to produce free bilirubin and precipitate.
Bile retention is a necessary condition for intrahepatic bile duct stone formation, and only under conditions of bile retention can the components of bile be deposited and form stones. Bile retention is caused by inflammatory biliary strictures and biliary malformations; increased pressure in the distal bile ducts of obstruction, bile duct dilatation, and slow bile flow facilitate stone formation.
In addition, mucin, acidic mucopolysaccharide, immunoglobulins and other macromolecules in bile, inflammatory exudates, shed epithelial cells, bacteria, parasites, and metal ions in bile are involved in stone formation.
Clinical symptoms
The clinical manifestations of intrahepatic bile duct stone disease can be multifaceted depending on the course and pathology of the disease, ranging from stones confined to a certain segment of the intrahepatic bile duct without obvious clinical symptoms in the early stage to advanced cases of biliary cirrhosis, hepatic atrophy, liver abscess and other complications in the later stages of the intrahepatic bile duct system.
The symptoms of intrahepatic bile duct stones are very atypical. During the interval of the disease, they may be asymptomatic or may only present as mild discomfort in the epigastrium. In the acute phase, however, symptoms of acute septic cholangitis or Charcot’s triad of varying degrees may be present, mostly due to combined extrahepatic bile duct stones. The clinical presentation is mainly acute cholangitis, including the triad of biliary obstruction (pain, chills fever, jaundice) the quintuplet of severe cholangitis.
In patients without combined extrahepatic bile duct stones, when intrahepatic bile duct stones in one side or one lobe cause intrahepatic bile duct obstruction in one half of the liver or one hepatic segment with secondary infection, systemic infection symptoms such as chills and fever may occur, and even in the presence of psychiatric symptoms and shock and other manifestations of acute severe cholangitis, the patient may still have no obvious abdominal pain and jaundice. Physical examination may reveal asymmetric enlargement and pressure pain in the liver, which is often misdiagnosed as liver abscess or hepatitis. These periodic intermittent attacks are the characteristic clinical manifestations of intrahepatic bile duct stones.
The clinical presentation of intrahepatic bile duct stones is characterized by intermittent right upper abdominal pain with fever. In the absence of symptoms of infection, the patient may be conscious of peripheral fever, often without significant jaundice. However, in some patients, jaundice may occur when the entire biliary system is obstructed by biliary tract infection. In some patients, there is only mild epigastric discomfort and no typical biliary tract infection symptoms in the early stage, but in the later stage, serious complications such as biliary cirrhosis, hepatic atrophy and liver abscess may occur when the stones spread throughout the biliary tract system both inside and outside the liver. A few intrahepatic bile duct stones become cancerous due to long-term inflammation.
Features of intrahepatic bile duct stones.
1. age of onset 30-50 years.
2. epigastric pain, which may be typical biliary colic or persistent distension, with some patients having insignificant pain and very strong chills and fever with periodic attacks.
3. there may be a long history of biliary tract disease, or a history of acute cholangitis with chills and fever and jaundice.
4. frequent painful discomfort in the affected hepatic area and lower chest, often radiating to the back and shoulders.
5, in case of obstruction of one hepatic duct, there may be no jaundice or very mild jaundice.
6.When combined with severe cholangitis, the general condition is more serious and the recovery is slower after acute attack.
7. on examination, pressure pain and percussion pain in the liver area are obvious, and the liver is asymmetrically enlarged with pressure pain.
8. systemic condition is significantly affected, 90% of patients have hypoproteinemia and 1/3 of patients have significant anemia
9, advanced stage with hepatomegaly, splenomegaly and manifestation of portal hypertension.
Diagnosis
The diagnosis of intrahepatic bile duct stones, in addition to clinical awareness of the disease, relies mainly on imaging findings to confirm the diagnosis. The main diagnostic methods applied are mainly ultrasound, biliary X-ray, CT, PTCD, ERCP, biliary subscopy, MRCP, cholangioscopy, etc.
1.B ultrasound diagnosis
Ultrasound is a non-invasive test, convenient and easy to perform, and is the preferred method for the diagnosis of intrahepatic bile duct stones, with an estimated diagnostic accuracy of 50%-70%. The ultrasound image of intrahepatic bile duct stones has many variations, and generally requires dilatation of the bile duct distal to the stone to make the diagnosis of intrahepatic bile duct stones, because calcification of the intrahepatic duct system also has a stone-like image performance.
The diagnosis of intrahepatic bile duct stones is not disturbed by intestinal gas, and the accuracy of diagnosis is better than that of extrahepatic bile duct stones. The correct diagnosis rate is 70% to 80%. The difficulty in differentiating intrahepatic calcified points from intrahepatic bile duct stones by ultrasound lies in the fact that if intrahepatic point-like or mass-like echogenicity, followed by acoustic shadow, is not typical of striated echogenicity, followed by acoustic shadow, then it is difficult to diagnose intrahepatic bile duct stones by ultrasound alone. It should be combined with other means to make a comprehensive judgment.
The typical image of intrahepatic bile duct stones with ultrasound diagnosis is a striated echogenicity with posterior traction and acoustic shadowing, and the distal bile ducts are obviously dilated, which may be due to biliary obstruction and complications of bile duct stenosis caused by stones. It has been reported that the use of intraoperative ultrasound (intraoperative comprehensive ultrasound scan on the liver and diaphragm) can improve the diagnosis rate of intrahepatic bile duct stones to 91% and reduce the residual stone rate to 9%.
2.CT diagnosis
Because intrahepatic bile duct stones are mainly pigmented stones containing calcium bilirubin, the calcium content is high, so it can be clearly shown in CT photos, and the diagnostic compliance rate of CT is 50%-60%. CT can also show the location of the hepatic portal, bile duct dilatation and changes in liver hypertrophy and atrophy, and systematic observation of all levels of CT photos can understand the distribution of stones in the intrahepatic bile duct.
3.X-ray cholangiography
X-ray cholangiography (including PTC, ERCP, TCG) is the classic method used for the diagnosis of intrahepatic bile duct stones, and is generally able to make a correct diagnosis, with a diagnostic compliance rate of 80%-90%, 70%-80% and 60%-70% for PTC, ERCP and TCG. anatomical variations of the intrahepatic biliary system and the extent of stone distribution. Cholangiography should pay attention to the following issues.
(1) There should be multidirectional radiographs.
(2) When a segment or lobe of the liver is not visualized, attention should be paid to the differentiation, as stone obstruction is only one of the causes, and other tests should be performed for differentiation.
(3) Do not settle for a particular lesion diagnosis, as this may result in a missed diagnosis.
(4) When analyzing cholangiography films, obtain the most recent film possible, as the disease may progress.
4.Percutaneous transhepatic percutaneous cholangiography (PTC, PTCD)
There are three kinds of PTC and PTCD puncture routes: anterior, posterior and lateral. The lateral route has a high success rate, few complications, easy operation and clear images during imaging. For those who have intrahepatic bile duct stones diagnosed by ultrasound, PTC and PTCD have good differential diagnostic value. Especially, the success rate of ultrasound-guided PTC is high. It can be considered for those who do not have surgery and want to determine intrahepatic bile duct stones.
5.Clinical application of selective retrograde cholangiopancreatography (ERCP), biliary subcholangioscopy and choledochoscopy
ERCP selective cholangiography has a high diagnostic value for intrahepatic bile duct stones. It can clearly show intrahepatic bile duct stones, determine the location, size and number of stones, and the narrowing or distal dilatation of intrahepatic bile ducts. However, the following points should be noted:
(1) During ERCP, the contrast agent injected should be sufficient to fully show the intrahepatic bile ducts in order to clearly diagnose intrahepatic bile duct stones.
(2) After ERCP bile duct visualization, the head-low, foot-high, prone position can be used so that the intrahepatic bile ducts can be fully perfused and visualized by the contrast medium.
(3) A catheter with a balloon can be used. After ERCP bile duct visualization, the balloon located at the duodenal papilla is inflated or filled with water to block the papilla so that the contrast agent will not flow into the intestine and the intrahepatic bile duct is fully visualized. It is of great value for the diagnosis of intrahepatic bile duct stones.
Recently, it has been reported that ERCP dual imaging can improve the diagnosis of gallbladder stones. The method is to inject an appropriate amount of air after ERCP bile duct visualization. With good filling of the intrahepatic bile duct and its 2nd level branches, it is expected that there should be a better imaging of intrahepatic bile duct stones. For patients with unresected gallbladder, about 5 to 10 ml of air is injected, and if the gallbladder has been removed, about 2 to 3 ml of air is injected.
The biliary subscope is a thinner subscope placed through the biopsy duct of the parent scope. The diameter of the biopsy duct of the mother scope is 5.5 mm, and the outer diameter of the daughter scope is 4.5 mm. only the mother scope is used to perform ERCP, and then high-frequency electric resection (ECT) is performed on the duodenal papilla, which is usually a small incision of 0.5-1.0 cm or dilatation of the duodenal papilla to facilitate the entry of the daughter scope into the common bile duct, which allows direct observation of the common bile duct and 1 to 2 intrahepatic bile ducts. It can determine whether intrahepatic bile duct stones exist and their size, location and number, and whether the intrahepatic bile duct is narrowed and dilated. It has greater diagnostic value. However, it is not easy to popularize because the biliary subscope is more expensive and easy to wear out.
Cholangioscopy includes preoperative, intraoperative and postoperative modalities. Preoperative choledochoscopy is done with light PTC and thicker catheters are replaced weekly, and sinus tracts are formed after 5 to 6 weeks. Then the scope is entered through the sinus tract and the intrahepatic bile duct is viewed directly, which allows diagnosis of intrahepatic bile duct stones and parallel stone extraction treatment. Intraoperative choledochoscopy is a surgical procedure in which the common bile duct is incised and the scope is passed through the incision to observe intrahepatic bile duct stones and to extract them for treatment. Postoperative cholangioscopy is performed through the sinus tract formed by the postoperative “T” shaped drainage tube (usually 6 weeks after surgery) to diagnose and treat intrahepatic bile duct stones. Cholangioscopy is valuable for the diagnosis and treatment of intrahepatic bile duct stones.
6.Magnetic resonance cholangiopancreatography (MRCP)
A new examination method different from ERCP, it is non-invasive and can diagnose intrahepatic and extrahepatic bile duct stones without duodenoscopy. However, MRCP image clarity is slightly inferior to that of ERCP and needs to be improved and enhanced technically. It has a greater diagnostic value for intrahepatic bile duct stones, but it is more expensive and not easy to be popularized. In conclusion, ultrasound, ERCP and cholangioscopy are the preferred methods for the diagnosis of intrahepatic bile duct stones because of their greater diagnostic value, simplicity and ease of use. Especially, ERCP and cholangioscopy are more accurate than B ultrasound in the diagnosis of intrahepatic bile duct stones. After the detection of intrahepatic bile duct stones by ultrasound, the above methods should be routinely performed to exclude misdiagnosis by ultrasound and also to remove the stones under direct vision by cholangioscopy.
Ancillary tests
Bile duct manometry Bile duct manometry can be used to find out whether bile excretion through the bile duct is normal. For intrahepatic bile duct stones in one branch, biliary manometry is of little clinical significance. However, for stones in the left and right hepatic ducts near the porta hepatis with bile duct stenosis, poor bile excretion can be detected, causing bile duct dilatation, bile retention and increased biliary pressure above the lesion. Electronic bile duct manometry is now available to accurately measure the pressure in the bile ducts and should be chosen for use according to the condition.
Pathology
The main pathological changes in intrahepatic cholestasis are biliary obstruction and infection; due to the direct relationship between the hepatobiliary system and the parenchymal cells of the liver, severe hepatobiliary cholestasis is often accompanied by severe hepatocellular damage, even leading to extensive hepatocellular necrosis, which becomes the main cause of death in benign biliary diseases. Complications of intrahepatic bile duct stones include acute phase complications and chronic phase complications.
(i) Acute complications
The acute complications of intrahepatic bile duct stone disease are mainly biliary tract infections, including severe hepatic cholangitis, biliary liver abscess and accompanying infectious complications. The causative factors of infection are related to obstruction of the stones and inflammatory narrowing of the biliary tract. Complications in the acute phase not only have a high mortality rate, but also seriously affect the outcome of the procedure.
(ii) Complications in the chronic phase
Chronic complications of intrahepatic cholestasis include systemic malnutrition, anemia, hypoproteinemia, chronic cholangitis and biliary liver abscess, multiple hepatic bile duct stenosis, hepatic lobe fibrosis and atrophy, biliary cirrhosis, portal hypertension, liver failure, and delayed hepatic bile duct cancer associated with long-term biliary tract infection and bile retention. Complications in the chronic phase of intrahepatic choledocholithiasis increase both the difficulty of surgery and affect its outcome.
Treatment
Nowadays, with the continuous improvement of medical treatment, the combination of surgery and lithotripsy, lithotripsy and lithotripsy is widely used in clinical practice, making the treatment of intrahepatic bile duct stones not only more targeted and accurate, but also safer and more effective. Compared with the treatment of simple gallbladder stones and extrahepatic bile duct stones, the treatment of intrahepatic bile duct stones indeed has many difficulties, such as the inability to completely remove stones, the narrowing of intrahepatic bile ducts which makes the bile drainage poor, and the re-formation of stones. At present, the treatment of intrahepatic bile duct stones mainly adopts a comprehensive treatment method based on surgery.
1.Surgical treatment: The purpose is to remove the stones as much as possible, to release the obstruction and stenosis of the bile duct, and to eliminate the infectious lesions in the liver, so that the bile can be drained smoothly. The main methods of surgery are: ① high bile duct dissection and stone extraction; ② bile and intestinal drainage; ③ elimination of infectious lesions in the liver, etc.
2.Chinese medicine treatment: In addition to surgery and other comprehensive treatment, patients can cooperate with acupuncture and take anti-inflammatory and biliary herbs to control the inflammation and promote the discharge of stones.
3. Treatment of residual stones: Once the patient is found to have residual stones in the bile duct via T-tube imaging after surgery, the T-tube can be removed after the sinus tract is formed and the fiberoptic choledochoscope can be inserted via the sinus tract to remove the stones with stone extraction forceps and mesh basket under direct vision. If the stone is too large, laser lithotripsy, microblast lithotripsy or other methods can be used to break up the residual stone into small pieces before removal.
In general, patients with intrahepatic bile duct stones have no obvious clinical symptoms, but this stationary state will not remain unchanged. In case of cold, overexertion or improper diet, the stones in the intrahepatic bile ducts may change from “static” to “moving” and the corresponding symptoms may appear. Therefore, patients should cooperate with their doctors for long-term observation and prevention, regardless of the presence or absence of symptoms, the number of stones, their size and whether they cause liver lesions. Patients should also have regular ultrasound examinations of the liver and gallbladder and biochemical tests of liver function, so that they can keep track of the location and nature of the stones and whether there are secondary lesions in liver function.
4.Treatment progress
Chinese medicine stone removal therapy Chinese medicine stone removal therapy is suitable for the discharge of smaller stones or sediment-like stones, and is mainly used for the treatment of common bile duct stones. Since intrahepatic bile duct stones are mostly accompanied by intrahepatic bile duct stenosis, the efficacy is poor. However, for stones close to the intrahepatic bile duct in the porta hepatis, especially small stones or sediment-like stones, the effect of stone removal is more satisfactory. The Chinese medicine “stone removal granule” and “stone removal punch” can also be used for stone removal treatment of intrahepatic bile duct stones.
Lithotripsy treatment Lithotripsy of cholesterol stones Methyl tertiary butyl ether (MTBE) can dissolve cholesterol stones 50 times more than caprylic triglyceride in in vitro lithotripsy test. Clinical trials have been reported abroad. The lithotripsy cycle of glyceryl caprylate is 10-14 days, while MTBE takes only 4-4.5h. MTBE is still more toxic to the body, and an improved version is being studied.
Treatment of bilirubin stones The orange peel 1 and 2 developed in China can be used for the treatment of bilirubin stones with good effect.
Lithotripsy by infusion In the past, the lithotripsy treatment of intrahepatic bile duct stones relied on the “T” shaped tube for infusion. This method is convenient and easy to perform. Nowadays, lithotripsy can be instilled under the condition of PTCD (percutaneous transhepatic choledochotomy) sinus cannulation, or the nasobiliary catheter can be retrograde inserted through the duodenoscope and lithotripsy can be injected through the nasobiliary catheter.
Preoperative, intraoperative and postoperative choledochoscopic application Preoperatively, the sinus tract is established via PTC (percutaneous transhepatic biliary tract puncture), the dilatation tube is changed weekly, and when the sinus tract is dilated to 5-6 mm, the choledochoscope is delivered via the sinus tract. Intraoperatively, the common bile duct can be incised and fed into a tightly sterilized choledochoscope; postoperatively, the sinus tract formed by the “T” shaped drainage tube can be fed into the choledochoscope. The choledochoscope can be used preoperatively, intraoperatively, and postoperatively for lithotripsy.
Burhenne et al. designed a lithotripter and lithotripter mesh to remove intrahepatic bile duct stones under X-ray, with a success rate of 90%. Since lithotripsy is still a non-direct vision procedure with blindness, it is not universally accepted. In contrast, choledochoscopic treatment of intrahepatic bile duct stones is a direct-view procedure that facilitates the detection of stones and concomitant intrahepatic bile duct strictures, and has a higher success rate when combined with mesh basket extraction. When intra-biliary stenosis is found, the stone cannot be seen directly, but there is a cloud of flocculent material drifting out from the stenosis, which is called “cloudy sign”, indicating that there may be a stone behind the stenosis. The stone can be retrieved by mesh basket, or after lithotripsy. There are many lithotripsy methods, such as laser lithotripsy, liquid lithotripsy, gas lithotripsy and ultrasonic lithotripsy. The air-elastic lithotripsy is more effective and does not damage the bile duct wall. However, the lithotripter rod of air-elastic lithotripter is a metal rod, and excessive bending will lead to the decrease of lithotripter effect. The most common application of electrohydraulic lithotripsy is good, but improper use can cause damage to the bile duct wall. Stones can be removed through a narrow opening after intrahepatic bile duct stone crushing. In addition, laser lithotripsy can cause thermal damage to the bile duct wall, and ultrasonic lithotripsy can cause damage to the bile duct and surrounding tissues.
It is reported that: airway lithotripters are produced by WOLF (Germany) and LITHC-LAST (Switzerland). It consists of three parts: air compression pump, pneumatic pulse release system, handle and probe. Under the direct view of the choledochoscope, after the stone is found, the probe of the pneumatic ballistic lithotripter is inserted along the instrument hole of the choledochoscope, inserted to 10 mm before the choledochoscope, aligned with the center of the stone, and the handle switch is pressed to impact the probe, so that the stone is broken by the back and forth movement of the probe. Each time the stone is crushed for 1~3s, the stone can be crushed in 1~3 times. The stone is then removed with the lithotripsy net or flushed out. For stones in intrahepatic secondary bile ducts and above, due to the deep bile duct location and tortuous stroke, the energy of impact will be depleted after excessive bending of the probe, and the effect will not be satisfactory.
Application of biliary subscope The basic structure and performance of the mother mirror are the same as that of the common duodenoscope. According to ERCP operation, the mother scope is placed in the duodenal papilla area, and high-frequency electric duodenal papillotomy is performed to cut the papilla opening to 1.0 cm. The subscope is inserted from the biopsy duct, and the subscope is sent into the intrahepatic bile duct to search for intrahepatic bile duct stones, and the stones are removed with a lithotomy net or crushed and removed.
Surgical stone extraction
Bile-intestinal anastomosis The most commonly used approach is the jejuno-biliary Roux-Y anastomosis. The second- and third-level intrahepatic bile ducts are exposed, the stones are removed, the bile duct strictures are released, and an enlarged anastomosis is made. The anastomosis is extended as far as possible to the left or right side of the liver.
Lobectomy The stone is located on one side of the liver lobe and cannot be easily removed.
Subcutaneous blind loop creation The creation of a blind loop not only serves as drainage but also avoids reoperation. It reduces the chance of reoperation.
Recurrence of intrahepatic bile duct stones
Patients with intrahepatic choledocholithiasis who have undergone surgical or choledochoscopic stone extraction have recurrence of intrahepatic choledocholithiasis, possibly in different branches of the intrahepatic bile duct. This is a difficult problem in the treatment of intrahepatic bile duct stones. The causes of recurrence are the same as the causes of intrahepatic bile duct stones and are mainly related to secondary bacterial infections and bile retention. Escherichia coli, Clostridium difficile and Bacillus pseudomallei have the activity of β-glucuronidase, which can hydrolyze conjugated bilirubin into free bilirubin, which is insoluble in water and combines with calcium ions in bile to form calcium bilirubin, causing stone recurrence. In addition, in some patients, hepatic bile duct stenosis occurs again, resulting in stone recurrence. It is more common in the left hepatic duct. In conclusion, the causes of intrahepatic bile duct stone formation and recurrence need to be studied in depth.
Dietary care
The liver and gallbladder are both important digestive organs of the body, and their secreted and concentrated bile is an important part of the digestive juices. The body relies on bile to emulsify and break down the fat it consumes before it can be digested and utilized. After suffering from intrahepatic bile duct stones, the impaired liver function and obstructed bile duct can affect the secretion, excretion and concentration of bile in the patient’s body, making the composition and quantity of bile abnormal, if the intake of high-fat food is not controlled at this time, it will certainly accelerate the formation or increase the size of stones in the bile duct. Therefore, the recipes for patients with intrahepatic bile duct stones should follow the principles of high sugar, high protein, high fiber and low fat, with more fish, eggs, lean meat and fresh vegetables and fruits, and limit the intake of starchy staple foods (rice, noodles, etc.). If necessary, patients can also take Chinese medicine with bile dispelling effect under the guidance of doctors to facilitate the regeneration of liver cells and bile secretion, promote the discharge of small and medium-sized intrahepatic bile duct stones and sediment-like stones, and reduce the chance of new stone formation. People suffering from intrahepatic bile duct stones should quit smoking and limit alcohol, avoid overeating or eating irritating food, because improper diet is often the direct cause of the patient’s morbidity. In addition, maintaining a good mental state, avoiding all kinds of adverse psychological stimuli and cultivating good habits are also effective measures to prevent and treat the disease.
1, try to reduce the amount of fat, especially animal fat consumption, do not eat fatty meat, fried food, as far as possible, vegetable oil instead of animal oil.
2, a considerable part of the formation of cholecystitis and cholelithiasis with high cholesterol content in the body and metabolic disorders are indeed related, so to limit the roe, egg yolk of various eggs and various carnivorous animal liver, kidney, heart, brain and other foods with high cholesterol content.
3, cooking food to steam, boil, stew, braise is better, do not eat a lot of fried, fried, burnt, baked, smoked, pickled food.
4, increase the amount of fish, lean meat, soy products, fresh vegetables and fruits and other foods rich in high-quality protein and carbohydrates, to ensure the supply of heat, so as to promote the formation of liver glycogen and protect the liver.
5, eat more tomatoes, corn, carrots and other foods rich in vitamin A to keep the gallbladder epithelial cells sound, to prevent the epithelial cells from shedding to constitute the core of stones, thus inducing stones, or making stones increase in size and number.
6, if the conditions permit, usually can drink more fresh vegetables or melon juice, such as watermelon juice, orange juice, carrot juice, etc., and increase the number and quantity of drinking water and eating, in order to increase the secretion and excretion of bile, reduce the inflammatory reaction and bile stasis.
7.Eat less fibre-rich food such as daikon, celery, etc. to avoid increasing gastrointestinal motility due to difficulty in digestion, which can trigger biliary colic.
8, quit smoking and alcohol and eat less spicy and stimulating food, strong condiments, such as mustard oil, to avoid stimulating the gastrointestinal tract and triggering or aggravating the condition.
9, it is advisable to enter the light, easy to digest, less residue, the temperature is appropriate, non-irritating, low-fat liquid or semi-liquid diet, do not want a moment of pain and “let go”, eat and drink, so as not to cause unnecessary trouble, and even induce biliary bleeding and life-threatening.
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