What causes gallstones?
As a general rule of stone formation, they have the basic processes of precipitation, precipitation, nucleation and accumulation growth of bile components. The pathogenesis includes several elements, firstly, the bile must be supersaturated with cholesterol or calcium; secondly, the solute must nucleate and precipitate as solid crystals from the solution; thirdly, the crystals must aggregate and fuse to form stones, and the crystals grow and collect in the mucus, gel that spreads across the wall of the gallbladder, and the impaired emptying of the gallbladder facilitates the formation of gallstones.
Cholesterol stones —- are formed on the basis of an imbalance in the ratio of cholesterol, bile acids and lecithin in the bile, resulting in supersaturation of cholesterol in the bile and crystallization, precipitation, aggregation and stone formation. Most of the cholesterol in bile originates from the biosynthesis of hepatocytes rather than the secretion of cholesterol from the diet. The formation of cholesterol stones is mainly due to the supersaturation of cholesterol in the bile synthesized by hepatocytes and the nucleation of cholesterol crystals by proteins in the bile, while other factors are attributed to the impairment of the motor function of the gallbladder, which act together to stagnate the bile and promote the formation of gallstones. In addition, some studies have shown that changes in prostaglandin synthesis in the gallbladder and high calcium concentrations in the bile may also contribute to gallstone formation. In some patients, the prerequisite for gallstone formation is bile sludge production. The so-called bile sludge is composed of stagnant glycoproteins containing cholesterol crystals. This bile sludge can be detected on ultrasound and may be the only abnormality found on ancillary testing in patients with biliary colic, pancreatitis or cholangitis.
Bile pigment stones —- include both black stones and brown stones. Black stones form mainly in the gallbladder in patients with hepatic sclerosis or chronic hemolytic disease, while brown stones can form both in the gallbladder and in the bile duct. Bacterial infection is the main cause of primary bile duct stone formation. Primary bile duct stones are common in Asia, and the source of infection may be attributed to parasites such as Toxoplasma gondii or other less clear causes.
The prevalence of gallstones increases with age and is more prevalent in women. Pregnancy, obesity, westernized diet, and total parenteral nutrition may increase the risk of gallstones. In addition, ethnic factors are also associated with the incidence of gallstones, for example, the prevalence rate of western American Indians is more than 75%, which is the highest incidence of gallstones in the world.
A survey of 11,342 gallstone patients in 26 provinces and cities in China from 1983 to 1985 showed that the distribution and type of gallstones were related to geography, diet, occupation, and infection. The incidence of gallbladder stones or cholesterol stones was higher in those who ate more protein, fat, or sugar in their diet, while the incidence of bile duct stones and bile pigment stones was higher in those who ate more ordinary diet or vegetables. Bile duct stones are about 3-5:1 in urban areas and 15:1 in rural areas. 70% of employees have gallbladder stones and 20% have bile duct stones; 60% of workers have gallbladder stones and 30% have bile duct stones; only 25% of farmers have gallbladder stones and 65% have bile duct stones. Cholesterol stones 73% in the gallbladder, 17% in the intra- and extra-hepatic bile ducts; bile pigment stones 62% in the intra- and extra-hepatic bile ducts, 27% in the shifting T shirk plus 0% to 20% of men and 20% to 40% of women suffer from gallstone disease, the latter causing about 10,000 deaths per year. More than 500,000 people have their gallbladders removed each year because of gallstone-related diseases, at a cost of more than $6 billion.
The main reasons for the “preference for women over men” in gallstones may be.
1. Prefer to be quiet and less active. Many women, especially middle-aged women, tend to spend more time at home and less time exercising and doing physical work, which inevitably decreases the contraction of their gallbladder muscle over time and delays the emptying of bile, easily causing bile stasis and cholesterol crystals to precipitate, creating the conditions for the formation of gallstones. In addition, the high level of estrogen in women affects the formation of glucuronide bilirubin in the liver, which increases non-conjugated bilirubin, and estrogen affects the emptying of the gallbladder, causing stagnation of bile and sweat and promoting the formation of stones. The incidence of gallstones increases significantly in those who use estrogen after menopause.
2, physical obesity. Many women usually love to eat high-fat, high-sugar, high cholesterol drinks or snacks, the direct result of this hobby is body fat, and obesity is an important basis for the development of gallstones. Research shows that people who weigh more than 15% of the normal standard, the incidence of gallstones is 5 times higher than normal. 40 years old and above fat women, is the highest incidence of gallstones, at this time, female estrogen will make more cholesterol gathered in the bile.
3, do not eat breakfast. I’m afraid that modern women do not eat breakfast more than they eat breakfast, and long-term skipping breakfast will increase the concentration of bile, which is conducive to bacterial reproduction and easy to promote the formation of gallstones. If you insist on eating breakfast, you can promote the flow of some bile, reduce the viscosity of the bile stored overnight, reducing the risk of gallstones.
4. Multiple pregnancies. During pregnancy, women are prone to biliary tract function disorders, resulting in smooth muscle contraction weakness, so that the gallbladder bile retention, coupled with the relative increase in blood cholesterol during pregnancy, prone to precipitation, the chance of forming gallstones is greatly increased, and the incidence is higher in women with multiple births.
5, snacks after meals. Now many families in China can see the situation, the family after dinner, sitting leisurely on the sofa, while eating snacks and chatting while watching TV. This habit of sitting and eating snacks after meals may be one of the reasons for the high incidence of gallstones in China. When a person is in a curled position, the intra-abdominal pressure increases, the gastrointestinal tract peristalsis is restricted, which is not conducive to the digestion and absorption of food and bile excretion, sitting after a meal hinders the reabsorption of bile acids, resulting in an imbalance in the ratio of cholesterol to bile acids in bile, cholesterol is easy to deposit.
6, cirrhosis of the liver. This is related to the lowering of estrogen inactivation function in the body of patients with cirrhosis, the lowering of estrogen inactivation function in the body, the higher estrogen level, coupled with the low contraction function of the gallbladder in cirrhosis, poor emptying of the gallbladder, biliary varices, elevated bilirubin in the blood and other factors can cause gallstones.
7, genetic factors. Genetic factors obviously play an important role in specifying the risk of gallstones. Gallstones are more frequently produced in close relatives of patients with cholesterol cholelithiasis. The fact that local Americans in the southwestern United States have a high risk of cholesterol gallstone disease (>80%) seems to include a genetic factor.
What are the manifestations of gallstones and how are they diagnosed?
Gallbladder stones with a history of acute attacks are usually not difficult to diagnose based on the clinical presentation. Ultrasound examination can correctly diagnose gallbladder stones by showing a light mass in the gallbladder and an acoustic shadow behind it, with a correct diagnosis rate of 95%. Oral cholecystography can show the shadow of stones in the gallbladder. The finding of biliary sand or cholesterol crystals in the gallbladder bile obtained during duodenal drainage (i.e., beta bile) aids in the diagnosis.
Symptoms of gallbladder stones depend on the size and location of the stones, as well as the presence of obstruction and inflammation. About 50% of patients with gallbladder stones are asymptomatic for life, known as occult stones. Larger gallbladder stones may cause symptoms of indigestion such as stuffiness and distension 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 obstruct the gallbladder duct after a full meal, eating fatty foods, or lying down at night. Due to the contraction of the gallbladder, smaller stones may pass through the cystic duct into the common bile duct and cause obstructive jaundice, then some stones may be discharged from the bile duct into the duodenum, and some stones remain in the bile duct as secondary bile duct stones. Stones may also obstruct the bile duct for a long time without infection and only form a fluid in the gallbladder, at which point an enlarged gallbladder without obvious pressure can be palpated. In the absence of infection, gallbladder stones usually have no specific signs or only mild pressure pain in the right upper abdomen. However, when there is an acute infection, pressure and muscle tension in the mid-upper abdomen and right upper abdomen may be present, and sometimes an enlarged and painful gallbladder may be palpable. Murphy’s sign is often positive.
What are the clinical features of hepatobiliary stones?
Hepatobiliary stones are stones in the intrahepatic bile duct system, so they are also called intrahepatic bile duct stones. They are often combined with extrahepatic bile duct stones, but there are also simple intrahepatic bile duct stones, also known as true intrahepatic stone disease. In recent years, the number of cases of intrahepatic bile duct stones has increased, and such stones account for 15.4% of the 474 cases of surgically confirmed gallstone disease reported in China. Most of them are accompanied by common bile duct stones. The classification of stones is mostly bilirubin stones.
The hepatic bile duct stones are mostly yellowish green masses or “mud-like” stones, mostly bilirubin calcium. Ascaris eggs are often found in the center of the stone, so some physicians believe that hepatobiliary stones are caused by bile duct obstruction due to biliary roundworms and bacterial infection.
Hepatobiliary stones are mostly found in the left lobe of the hepatic duct. The bile ducts at the confluence of the upper and lower hepatobiliary ducts in the left outer lobe of the liver are slightly enlarged, and the stones are mostly found in this area. Clinical features are mostly manifested as follows.
(1) Patients are younger than those with gallbladder stones, and some patients are associated with congenital abnormalities of the intrahepatic bile ducts. Patients often have a history of abdominal pain, chills, fever, and recurrent jaundice since early childhood.
(2) There is impairment of liver function, while gallbladder function may be normal. A variety of liver function abnormalities may occur during recurrent episodes, and alkaline phosphatase rises during intervals; prolonged disease may lead to atrophy and liver fibrosis of the liver lobe segments.
(3) Abdominal pain, jaundice and fever are the main symptoms, but the typical severe colic rarely occurs.
(4) Complications are numerous and more serious. The more common ones are purulent intrahepatic cholangitis, liver abscess, and biliary hemorrhage.
(5) Cholangiography may show dilated intrahepatic bile ducts without dilated extrahepatic bile ducts and small translucent areas in the hepatic ducts.
How should gallstones be treated?
(A) Non-surgical treatment of gallstones
1, lithotripsy (oral lithotripsy of bile acid and other drugs): The main mechanism of gallbladder stone formation is the change of bile physicochemical composition, the narrowing of bile acid pool and the increase of cholesterol concentration. In 1972, Danjinger was the first to apply goose deoxycholic acid, which successfully dissolved cholesterol stones in the gallbladder in 4 cases. However, this drug has certain toxic reactions on the liver, such as elevated glutamate transaminase, and can irritate the colon and cause diarrhea.
At present, the main drugs for lithotripsy 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 was performed once every six months during the treatment period to understand the dissolution of stones. Since the value of such lithotripsy drugs is expensive, and there are certain side effects and toxic reactions, and must be taken for life, if 3 months after stopping the drug, the cholesterol in the bile will become supersaturated again, and the stones will recur, according to statistics, the recurrence rate of 3 years can reach 25%, there are still some limitations of such lithotripsy treatment. In addition, some new drugs, such as Rowachol, metronidazole (metronidazole) also have some lithotripsy effect. In 1985, some people reported the use of percutaneous hepatic puncture to inject glycerol monolipid octanoate or methyl tert-butyl ether into the gallbladder, which can lithotripsy directly in the gallbladder and achieve certain efficacy.
2, contact lithotripsy (lithotripsy by PTC injection of glyceryl mono-octanoate and other drugs)
3.Extracorporeal shock wave lithotripsy (ESWL): In 1984, Lauerbwch first used extracorporeal shock wave to treat gallstone disease (extracorporeal shock wave-lithotripsy, ESWL for short). The commonly used shock wave lithotripsy machine is EDAP LT-01, which consists of 320 piezoelectric crystals embedded in a paraboloidal disc, synchronously emitting shock waves to form a 4 mm wide and 75 mm long aggregation area with an acoustic pressure of 9X107 PZ. The stones can be crushed. In addition, B-mode ultrasound imaging is used to localize the stones and monitor the process of lithotripsy.
The main indications for the treatment of gallbladder stones by shock wave lithotripsy are cholesterol stones in the gallbladder, negative stones on oral cholecystography, no more than 3 stones with a diameter of 12-15 mm, and only 1 stone with a diameter of 15-20 mm, and a normal contractile gallbladder function. Zhongshan Hospital of Shanghai Medical University has applied EDAP-LT 01 shock wave lithotripter to treat 687 gallbladder stone cases since January 1988, and the stone crushing rate was 98%. The disappearance rate of gallbladder stones 1, 2, 3, 4 and 6 months after one shock wave treatment was 27%, 33%, 40%, 45% and 50%, respectively. The side effects after treatment were mild, such as vague discomfort in the right upper abdomen (45%), biliary colic (16%) and weakness, and no complications of organ damage to the liver, bile, pancreas and gastrointestinal tract were observed.
In order to improve the disappearance rate after stone crushing, ursodeoxycholic acid (UDCA) 8 mg/kg/d was administered before and after shock wave to achieve the synergistic effect of stone crushing and lithotripsy. To consolidate the efficacy after the disappearance of stones, it can be continued for six months. This method is safe and effective, but there is still about 11.2% stone recurrence rate, expensive treatment, and strict treatment scope, which are all shortcomings.
4.In vivo contact lithotripsy (via choledochoscopic placement of liquid electrolysis machine, laser and other energy contact lithotripsy)
5.Lithotripsy by endoscopic minimally invasive surgery
6.Chinese medicine lithotripsy and lithotripsy for stone removal
(B) Surgical treatment of gallstones
1.Traditional open surgery to remove gallbladder stones
2.open abdominal exploration of bile ducts for stone extraction
3.Laparoscopic removal of gallbladder by microincision
4.Laparoscopy combined with choledochoscopy for bile duct extraction
How should gallstones be prevented?
Prevention of gallstones
Dietary regulation is the most ideal prevention method to prevent the occurrence of gallstone and gallbladder cancer. In addition, cold, greasy, high-protein, stimulating foods and strong alcohol are likely to create heat and bile accumulation, so they should be consumed sparingly.
Vegetables and fruits rich in vitamin A and vitamin C, fish and seafood can help clear the bile and dissolve stones, so you should eat more.
It is also very important to have a regular life, pay attention to the combination of work and rest, participate in regular physical activities, eat breakfast on time, avoid gaining weight, and reduce the number of pregnancies. Drinking a glass of milk every night or eating a fried egg for breakfast can cause the gallbladder to contract and empty regularly, reducing the time bile stays in the gallbladder.
Recent studies have also found that nut intake appears to reduce the risk of gallstones. A large portion of the fat source for a healthy diet comes from nuts.
Dietary Treatments for Gallstones
The causes of gallbladder stone formation are more complex, but changes in the composition of the bile, particularly the levels of bile salts and cholesterol in the bile, are an important factor in the formation of gallstones. Under normal circumstances, these two are kept in a certain proportional relationship in bile. Cholesterol is in a dissolved state and is excreted with the bile. If there is too little bile salt or too much cholesterol, the two lose their normal proportional relationship and the cholesterol becomes supersaturated, and the excess cholesterol in the bile precipitates and forms stones.
If there is also inflammation of the gallbladder, roundworm eggs, necrotic tissue and bile pigments, stones are more likely to form. Sugar stimulates insulin secretion from pancreatic β-cells, and insulin increases cholesterol, leading to supersaturation of cholesterol in the bile and the formation of gallstones.
Some people have 267 gallstone patients and 600 healthy people’s diet, the results of the survey analysis, the results show that the more sugar eaten, the higher the incidence of gallstones.
Therefore, to prevent the occurrence of gallstones, it is necessary to eat less sugar.
It is important to pay attention to dietary hygiene and avoid parasitic infections.
It is advisable to eat a low-fat diet, more fresh vegetables, fruits, lean pork, chicken, duck meat, egg whites.
Avoid eating fried food, animal fat and offal, and be careful with egg yolk, fish and crustaceans.
Avoid smoking, alcohol and spicy food.
Dietary modifications
The purpose of dietary therapy is to inhibit stone production and relieve pain caused by stone obstruction. The principles of dietary therapy are
The caloric supply should meet the physiological needs, but prevent excess, generally 1500 to 2400 kcal.
Limit fats to avoid stimulating gallbladder contraction for pain relief. The fat in the diet before and after surgery should be limited to about 20 grams, which can be slightly increased as the condition improves to improve the color and flavor of dishes and stimulate appetite. Avoid greasy, fried, deep-fried and fatty foods such as fatty pork, lamb, stuffed duck, fatty goose, butter, crispy snacks, cream cakes, etc.
Ten ways to prevent gallstones diet
1, drink more water, do not hold urine
Do not hold urine, drink more and more urine helps bacteria, carcinogenic substances and easy to stone substances quickly out of the body, reduce the chance of kidney and bladder victimization.
2.Drink less beer
Some people believe that beer can be diuretic and can prevent the occurrence of urinary stones. In fact, the wort of brewing beer contains calcium, oxalic acid, uronic acid and purine nucleotides and other acidic substances, they are used in each other, can make the body of uric acid increased, becoming an important cause of kidney stones.
3, meat, animal offal to eat less
Control the intake of meat and animal offal, because meat metabolism produces uric acid, animal offal is high purine food, decomposition metabolism will also produce high blood uric acid, and uric acid is the formation of stone ingredients. Therefore, the daily diet should be mainly vegetarian, and eat more fiber-rich food.
4. Eat less salt
Too salty diet will increase the workload of the kidneys, while salt and calcium have a synergistic effect in the body and can interfere with the metabolic process of drugs for the prevention and treatment of kidney stones. The daily salt intake should be less than 5 grams.
5, careful eating spinach
According to statistics, more than 90% of stones contain calcium, and calcium oxalate stones account for about 87.5%. If the amount of oxalate intake in food is too much, and the calcium oxalate in urine is in a supersaturated state, the extra calcium oxalate crystals may be precipitated from the urine and form stones. In the food, the highest oxalate is spinach, and spinach is one of the vegetables people often eat
6, do not drink milk before bed
As milk contains more calcium, and most of the stones contain calcium salts. The most dangerous factor for stone formation is the sudden increase of calcium concentration in the urine for a short time. 2 to 3 hours after drinking milk, it is the peak of calcium elimination through the kidneys, so it is in a sleep state, urine concentration, calcium through the kidneys more, so easy to form stones.
7, should not eat more sugar
After taking sugar, the concentration of calcium ions in urine, oxalic acid and acidity of urine will increase, and the increase of urine acidity will make calcium urate and calcium oxalate easy to precipitate, which will promote the formation of stones.
8.Eat early for dinner
If dinner is too late, when the peak of calcium discharge comes, people will already go to bed and fall asleep, so urine will be retained in the ureter, bladder, urethra and other urinary tract, which cannot be discharged in time, resulting in an increase in calcium in urine, which is easily deposited to form small crystals, and over time, gradually expand to form stones.
9, eat more vegetables and fruits
Vegetables and fruits contain vitamin B1 and vitamin C. Their final metabolites in the body are alkaline, and uric acid is easily dissolved in alkaline urine, which is beneficial to the treatment and prevention of stones.
10. Reduce protein intake
Some studies have shown that a high protein diet can increase the incidence of urinary stones. Therefore, moderation of protein in food, especially animal protein, is beneficial to all stone patients.
What diseases can be complicated by gallstones?
1. Gallstones may become cancerous. Gallstones are a cause of gallbladder cancer. The gallbladder is stimulated by chronic inflammation and bile acid and choline in gallstones for a long time, which can easily cause cancerous changes in gallbladder mucosa. Since gallbladder cancer patients often have gallstones, it is often misdiagnosed during diagnosis.
2.Secondary bile duct stones
3.Secondary infection
Carcinoma
Gallstones are the causative factor of gallbladder cancer. Chronic inflammation of gallbladder and stimulation of bile acid and choline in gallstones can easily cause cancerous changes in gallbladder mucosa. Since patients with gallbladder cancer often have gallstones, they are often misdiagnosed during diagnosis.
Malignant tumors in the bile duct (cholangiocarcinoma) can occur anywhere along the bile duct tree, with peak age of onset at 60-65 years old, and mainly present as jaundice, occasional pain and weight loss. Risk factors for cholangiocarcinoma include Toxoplasma gondii, congenital cystic dilatation of the bile ducts, sclerosing cholangitis, and ulcerative colitis. The clinical presentation and diagnosis of gallbladder cancer is similar to that of cholecystitis and is often found incidentally at the time of gallbladder removal. 90% of gallbladder cancers are adenocarcinomas. The one-year survival rate is only 14%.
The risk factors for gallbladder cancer are mostly the same as those for gallstones. Some Native American populations have a genetic predisposition to develop gallstones at a younger age and the incidence of gallbladder cancer is 5-10 times higher among them than in the general population. The duration and severity of gallstones are associated with risk factors for gallbladder cancer. Gallbladder cancer is particularly associated with large stones (>3 cm in diameter) or calcification of the gallbladder wall (porcelain gallbladder) in the presence of chronic inflammation, and these findings are therefore considered by many experts to be indications for cholecystectomy, even in asymptomatic patients. However, since the incidence of gallbladder adenocarcinoma in patients with gallstones is less than 1 in 1000, prevention of gallbladder cancer is currently not considered an indication for cholecystectomy in most patients with asymptomatic gallstones.