Gallbladder stones are mainly seen in adults, more in women than men, and their incidence increases with age after the age of 40. The stones are cholesterol stones or a mixture of cholesterol-based stones and black bile pigment stones.
Etiology
Gallbladder stones are associated with a variety of factors. Any factor that affects the ratio of cholesterol to bile acid concentration and causes bile stagnation can lead to stone formation. Individual regional and ethnic residents, female hormones, obesity, pregnancy, high-fat diet, long-term parenteral nutrition, diabetes mellitus, hyperlipidemia, after gastrectomy or gastrointestinal anastomosis, terminal ileal disease and ileal resection, cirrhosis of the liver, and hemolytic anemia can all cause gallbladder stones. The relatively high incidence of gallbladder stones in the northwest of China may be related to dietary habits.
Clinical manifestations
Most patients are asymptomatic and are only found during physical examination, surgery and autopsy, which is called stationary gallbladder stones. In a small number of patients, the typical symptom of gallbladder stones is biliary colic, which manifests as acute or chronic cholecystitis.
The main clinical manifestations are as follows.
1.Biliary colic
Patients often have colic due to contraction of the gallbladder or displacement of stones plus vagus nerve excitation after a full meal, eating fatty food or during sleep when the position changes, the stones are embedded in the abdomen or neck of the gallbladder, gallbladder emptying is obstructed, the pressure in the gallbladder rises, and the gallbladder contracts strongly. The pain is located in the right upper abdomen or epigastrium and is paroxysmal, or the pain may increase in paroxysms, radiating to the right scapula and back, and may be accompanied by nausea and vomiting. Some patients are unable to name the exact site of pain because of the severity of the pain. After the first appearance of biliary colic, about 70% of patients will recur within a year.
2.Hidden pain in the upper abdomen
Most patients only feel vague pain in the upper abdomen or right upper abdomen when they over-eat, eat high-fat food, work under stress or have poor rest, or have discomfort of fullness, belching and eructation, etc., which can be easily misdiagnosed as “stomach disease”.
3.Gallbladder fluid accumulation
When gallbladder stones are embedded for a long time or obstruct the gallbladder duct but not combined with infection, the gallbladder mucosa absorbs bile pigments in the bile. Mucus material is secreted, forming gallbladder effusion. The fluid is transparent and colorless, also known as white bile.
4.Other
(1) Rarely causes jaundice, which is milder.
(2) Small stones may enter the common bile duct through the cystic duct and become common bile duct stones.
(3) Stones from the common bile duct become embedded in the jugular abdomen through the sphincter of Oddi, leading to pancreatitis, called biliary pancreatitis.
(4) inflammation and chronic perforation of the gallbladder due to stone compression, which can result in cholecystoduodenal fistula or cholecystocolic fistula, and large stones entering the intestine through the fistula causing intestinal obstruction called gallstone intestinal obstruction
(5) Stones and long-term inflammatory stimulation can induce gallbladder cancer.
5.Mirizzi’s syndrome
Mirizzi’s syndrome is a special type of gallbladder stone, which is caused by the low confluence of the cystic duct and the common hepatic duct, and the persistent embedment in the neck of the gallbladder and the compression of the common hepatic duct by large cystic duct stones, resulting in the narrowing of the common hepatic duct. The clinical manifestations are recurrent episodes of cholecystitis and cholangitis, and marked obstructive jaundice. Imaging of the biliary tract reveals an enlarged gallbladder or enlarged, dilated common hepatic duct, and normal common bile duct.
Diagnosis
Based on the typical clinical history of colic, imaging examinations can confirm the diagnosis. Ultrasound examination is preferred, and the diagnosis of gallbladder stones is confirmed by the presence of a strong echogenic mass in the gallbladder, which moves with position change and is followed by an acoustic shadow. Only 10%-15% of gallbladder stones contain calcium, and the diagnosis can be confirmed by abdominal X-ray. However, they are not routinely examined.
Treatment
1.Laparoscopic cholecystectomy treatment is preferred
It is less invasive and more effective than the classic open cholecystectomy. Small incision cholecystectomy can be performed without laparoscopic conditions. Asymptomatic gallbladder stones generally do not require active surgical treatment and can be observed and followed up, but the following cases should be considered for surgical treatment.
(1) stone diameter ≥75px;
(2) Combined surgery requiring open abdomen.
(3) with gallbladder polyps >25px;
(4) thickening of the gallbladder wall
(5) calcification of the gallbladder wall or porcelain gallbladder.
(6) gallbladder stones in children.
(7) Combined diabetes mellitus.
(8) with cardiopulmonary dysfunction
(9) remote or underdeveloped transportation areas, field workers
(10) Gallbladder stones have been found for more than 10 years.
(2) When performing cholecystectomy, common bile duct exploration should be performed in the following cases
(1) Preoperative history, clinical manifestations or imaging examination confirm or highly suspect obstruction of the common bile duct, including obstructive jaundice, common bile duct stones, recurrent biliary colic, cholangitis and pancreatitis.
(2) Intraoperative confirmation of lesions in the common bile duct, such as intraoperative cholangiography confirming or palpating stones, roundworms, masses in the common bile duct, dilatation of the common bile duct over 25px in diameter, significant thickening of the bile duct wall, and finding pancreatitis or pancreatic head mass. Bile duct puncture to extract purulent, bloody bile or sediment-like bile pigment particles.
(3) Small gallbladder stones with the possibility of entering the common bile duct through the cystic duct. To avoid blind biliary exploration and unnecessary complications, intraoperative cholangiography or choledochoscopy is feasible. T-tube drainage is usually required after common bile duct exploration, which has certain complications.