Gallstones, or cholelithiasis, are the most common lesion in the biliary system. The biliary system is a system of ducts that produce and secrete bile in the body and consists of the gallbladder and bile ducts, the latter including the intrahepatic and extrahepatic bile ducts. Depending on the location of the stones, there are gallbladder stones, extrahepatic bile duct or intrahepatic bile duct stones. In clinical practice, most gallstones occur in the gallbladder, while in a few cases only bile duct stones are present, and the same patient may have gallstones from different sites at the same time. The term “gallstones” is generally used to refer to gallbladder stones, i.e. the disease caused by stones in the gallbladder, which is a common disease and is related to various factors such as living conditions, dietary habits, age and gender. There is no effective method to prevent the occurrence of stones, but it is possible to reduce or slow down the development of stones through reasonable adjustment of dietary structure and healthy lifestyle habits. Once gallbladder stones are found, correct treatment measures should be taken according to the specific situation. I. What are the causes of gallstones? The causes of gallbladder stones are very complex, and changes in the composition of the bile caused by various reasons can trigger stones. (1) Age factor, the incidence of gallbladder stones increases with age (4) dietary factors, dietary habits are the main factors affecting the formation of gallstones, and the incidence of gallbladder stones is significantly higher in those who eat low-fiber, high-calorie foods. Dietary factors are the easiest to control, so doctors often advise gallstone patients to “eat less fatty foods”, which can not only slow down the occurrence and development of stones, but also effectively reduce the stimulation of fatty foods on the gallbladder, which can reduce the chance of gallbladder inflammation. What are the clinical manifestations of gallstones? In fact, most patients with gallbladder stones may not have any clinical symptoms, i.e. “asymptomatic gallbladder stones”, which are mostly found by imaging during physical examination. Once the stones become symptomatic, they mostly appear as pain in the right upper abdomen (under the right side of the rib cage), with varying degrees of severity, often with paroxysmal colic, and may be accompanied by fever, nausea, vomiting and other symptoms; generally, pressure pain can appear when pressing the right upper abdomen (i.e., the location of the gallbladder), and sometimes the enlarged gallbladder can be felt. The diagnosis of acute cholecystitis can be confirmed by imaging tests such as ultrasound or CT, which can reveal enlarged gallbladder, blurred or thickened walls and stones in the gallbladder. Many patients with acute cholecystitis have constipation and abdominal distension, and sometimes the abdominal pain may improve after laxative treatment, which brings some interference to the clinical diagnosis, and at this time, the diagnosis of cholecystitis is mainly based on blood changes and ultrasound and other imaging changes. Patients with chronic cholecystitis have mild symptoms, often manifesting as discomfort in the right upper abdomen associated with eating, sometimes also at night, and generally the elevated blood image is not obvious. Third, how to treat gallbladder stones? The incidence of gallbladder stones is very high, but most patients who do not have any symptoms do not need special treatment. The treatment of gallstones includes diet control, medication and surgery, and the specific treatment should be decided according to the patient’s specific situation. First, asymptomatic gallbladder stones can be treated without any treatment, and many people carry stones for life without causing symptoms. For patients with high blood lipids or excessive intake of fatty foods, they can adjust their diet and lifestyle habits by eating less fatty foods and exercising more, and sometimes the stones may gradually shrink. This group of patients needs regular ultrasound examinations (once a year is sufficient and will be done routinely during physical examinations) to observe stone size, gallbladder size and cyst wall changes. If gallbladder atrophy or wall thickening is found during the follow-up, gallbladder cancer cannot be excluded and surgery is needed to remove the gallbladder. In another case, when a patient needs to undergo upper abdominal surgery (such as gastrectomy, partial hepatectomy, etc.) due to other diseases, doctors usually recommend removing the gallbladder with stones at the same time (even if it is asymptomatic), because the incidence of cholecystitis in patients increases after surgical disturbance, and the onset of cholecystitis after surgical operation increases the difficulty and risk of gallbladder removal surgery. Medication for gallstones is aimed at patients with chronic cholecystitis who often feel discomfort in the right upper abdomen. It should be noted that “lithotripsy” or even lithotripsy is not recommended for gallbladder stones, because smaller gallbladder stones are more likely to go down into the common bile duct, and the risk of common bile duct stones is much higher than gallbladder stones, and the treatment is more complicated. Therefore, do not believe the propaganda of so-called “lithotripsy” or “lithotripsy” treatment, but go to a regular hospital to receive regular treatment. Finally, surgical treatment. The most frequently asked question in outpatient clinics is “Is it possible to remove gallstones with biliary preservation?” Gallstone extraction has a long history, as does open cholecystectomy, but it was phased out in the late 20th century due to its high recurrence rate, and is now largely unavailable abroad. The answer to this question is no, as it has been reported that nearly 50% of patients have recurrent stones within 5 years of biliary stone extraction. If gallstones do require surgical treatment, cholecystectomy is the best option. With the progress of medicine, laparoscopic cholecystectomy is widely used, and the safety of surgery is greatly improved. Under what circumstances should the gallbladder be removed? As mentioned before, gallbladder stones do not necessarily require gallbladder removal, but gallbladder removal should be performed for gallstone disease combined with cholecystitis (clinical symptoms or imaging findings of inflammation). There are two types of cholecystitis, acute and chronic, and in principle both should be surgically removed. However, with the popularity of minimally invasive surgery, laparoscopic cholecystectomy has replaced traditional open cholecystectomy as the procedure of choice for the treatment of cholecystitis. Because of the presence of swelling and adhesions around the gallbladder during acute cholecystitis attacks and unclear anatomical levels, which increase the difficulty and surgical risk of laparoscopic surgery, most of them do not advocate performing cholecystectomy in the acute stage, but adopt conservative treatment to enable patients to pass the acute inflammation period, and then perform laparoscopic cholecystectomy after the inflammation has completely subsided (about 1 month after acute attack). For exceptional cases that cannot be relieved by conservative treatment, open cholecystectomy has to be chosen. Of course, laparoscopic cholecystectomy can also be performed selectively in the acute phase by experienced surgeons, but the corresponding surgical risk is significantly higher. In patients with chronic cholecystitis or gallstones after an acute attack, the clinical manifestations are not severe, and many people are reluctant to remove their gallbladder with a sense of luck. This is equivalent to planting a “time bomb” in oneself, as recurrent gallbladder infection itself increases the incidence of gallbladder cancer, and the cancer rate increases sharply with age. On the other hand, the mortality rate and treatment difficulty of acute cholecystitis in the elderly are greatly increased, and benign diseases that are well treated may be fatal in the elderly. Therefore, it is wise to choose the appropriate time to undergo cholecystectomy for patients with symptomatic gallbladder stones (especially those with recurrent episodes of acute cholecystitis), those with gallbladder wall thickening on imaging, and those with gallbladder atrophy. V. What should I pay attention to after gallbladder removal? The function of the gallbladder is to store, concentrate and discharge bile to help digestion and absorption of fatty foods. These functions will definitely be affected after removal of the gallbladder, mainly in the form of diarrhea after eating large amounts of fatty foods. However, as time goes by, the body will dilate the bile ducts to partially compensate for the function of the gallbladder, and it is usually able to digest and absorb food normally after 2 to 3 months. Therefore, after cholecystectomy, you should pay attention to low-fat diet, eat less greasy, fatty meat, egg yolk and other foods, do not overeat, and develop a good meal routine. To sum up: gallbladder stones are very common, surgery only when symptoms appear; gallbladder stone retrieval is not desirable, lithotripsy needs to be cautious; acute attacks try to preserve, lumpectomy is the first choice; gallbladder removal is not terrible, eat less greasy is the key.