History and Reality Zheng Yamin, General Surgery Department, Xuanwu Hospital, Capital Medical Universityv Gallstone disease has a long history – On June 8, 1975, Chinese archaeologists found a male corpse in the ancient tomb No. 168, Phoenix Hill, Jiangling County, Hubei Province, and found 270 gallstones in his gallbladder by autopsy. This ancient corpse is 2151 years old and is the earliest autopsy case of cholelithiasis found in the world. Reality v Gallstone disease has been around for a long time – in reality about 10% of adults suffer from gallstone disease, and in middle-aged women, the incidence of gallstone disease can be up to 15% and even up to 20% in the elderly. Gallstone disease gallbladder stones gallbladder inflammation what is the gallbladder? v The gallbladder is located below the liver, 8-12cm long, 3-5cm wide, with a capacity of about 30-60ml v The gallbladder is divided into three parts: bottom, body and neck v The wall of the gallbladder consists of three layers: mucous membrane, muscular layer and outer membrane v Functions: (1) storage of bile ( 2) concentration of bile (3) secretion of mucus (4) emptying of bile what is the gallbladder? Secretion: 800-1000ml/d Components: water, inorganic components (sodium, potassium, calcium, bicarbonate), organic components (bile pigments, bile salts, cholesterol, lecithin, fatty acids) Why do gallbladder stones form? { Cholesterol is the main component of the majority of gallstones { The over-saturation of cholesterol in the bile is necessary for the formation of cholesterol stones. { All gallstones are formed in the gallbladder, but stones can also form in the posterior end of bile duct strictures due to biliary stasis and in the bile ducts after gallbladder removal. Gallbladder stones v Age of onset, sex (4F: Forty, Female, Fatty, Fertility) v Pathogenesis: § Biliary cholesterol supersaturation § Nucleating factors: secretion of mucin § Abnormal gallbladder function: reduced contractility, bile stasis (1) Long-term high-fat, high-calorie diet increases cholesterol in the body or increases cholesterol synthesis in the liver, resulting in bile cholesterol supersaturation in the bile. (2) Certain intestinal diseases also leave cholesterol in a relatively supersaturated state due to the loss of bile salts. (3) Biliary tract infection, inflammation of the gallbladder wall, and its contractile function is reduced. (4) Stagnation of bile due to pregnancy and imbalance of the nervous system can also cause gallbladder stones. (5) Long-term fasting and intravenous nutrition can lead to bile stagnation in the gallbladder and stone formation. (6) Most of the stomach is removed or the vagus nerve stem is cut off, which can also delay the emptying of the gallbladder and facilitate the formation of gallstones. v Common diseases and prevalent diseases v Stone classification § Cholesterol stones : 80% are located in the gallbladder § Bile pigment stones : mainly occur in the bile ducts § Mixed stones : 60% in the gallbladder and 40% in the bile ducts X-ray examination often reveals (calcium salts) Gallstone classification (by composition) The cholesterol contained in the bile is too much to be dissolved and gradually deposited. They are mostly solitary, hard, round or oval, containing 98% cholesterol, with a yellowish or grayish-yellow appearance and smooth surface, and are not visible on X-ray. Bile pigment stones: variable in shape, soft and fragile, no core or stratification in cross-section, called “Oriental stones”. The stones are composed of bile pigment, calcium salts, bacteria, and worm eggs. The size of stones varies from small ones like sediment to large ones the size of soybeans, black or brownish red in appearance, more in number and smaller in size, often flowing with the discharge of bile, becoming common bile duct stones. The stones can be mixed with bile pigment or cholesterol stones, and can be formed by the deposition of cholesterol or bile pigment and calcium salts outside the original stones. Gallstones are classified (by location): ① Gallbladder stones: mostly cholesterol and mixed stones. ②Total bile duct stones: mostly bilirubin stones. ③ Intrahepatic bile duct stones: mostly bilirubin stones. Category Ⅰ is asymptomatic; Category Ⅱ is only with symptoms such as gastrointestinal distension and dyspepsia; Category Ⅲ is recurrent acute cholecystitis with biliary colic symptoms; Category Ⅳ is some special cases of advanced age and contraindications to surgery such as coronary heart disease and diabetes. Those manifestations are noteworthy. v Most patients can be asymptomatic for a long time or even for life. v Indigestion and fatty meal intolerance are usually symptoms of gallbladder disease, while manifestations such as belching, abdominal pain, and nausea can be symptoms of cholelithiasis, peptic ulcer, or functional stress. v It is difficult to make a diagnosis of gallbladder disease based on symptoms alone without supporting clinical signs and diagnostic studies. v Unlike other causes of Unlike other causes of colic, typical biliary colic is persistent and progressively worsens and remains for a period of time before gradually decreasing and lasting for several hours. v It is often accompanied by nausea and vomiting. In the absence of complications, chills and high fever are not present. The pain is most often located in the upper abdomen or right upper abdomen and radiates to the right scapular region. v Stones may or may not pass through the cystic duct with signs of obstruction. v Temporary obstruction of the cystic duct causes colic, while persistent obstruction causes inflammation and acute cholecystitis. What will you be tested for at the hospital? Ultrasound – the main method to diagnose gallbladder stones, with a positivity rate of 98% and specificity of 95%. Cholecystography CT examination X-ray plain film ECGv Gallbladder stones. Plain film shows three positive stones in the gallbladder area with slightly different morphology and surrounding calcification, each with a denser core. v Gallbladder stones. ultrasound shows a strong echogenic cluster in the gallbladder with a posterior acoustic shadow. v Gallbladder stones. CT plain scan shows stratified stones with a denser core. How is it treated? Symptoms may develop in about 2% of cases each year. In most of these cases, although there is a potential risk of serious complications, they do not consider it worthwhile to endure the pain, spend the money and risk surgery to remove an organ that never had clinical manifestations.v According to Academician Huang, surgery is recommended for asymptomatic gallbladder stones in the following cases: 1, gallbladder stones in diabetic patients; 2, non-functional gallbladder; 3, large gallbladder stones (larger than 2 cm); 4, porcelain gallbladder; 5, gallbladder stones found during upper abdominal surgery; 6, gallbladder stones associated with diseases of the upper abdominal organs, and the gallbladder can be removed at the same time during elective surgery. v Combined with diabetes mellitus, because the mortality rate of gallbladder stone disease with combined diabetes mellitus is 5 times higher than that of non-diabetic patients once complications of gallbladder stones occur, while the outcome of elective surgery cases is not different from that of non-diabetic patients. v The larger the gallbladder stones, the greater the relative risk of gallbladder cancer, especially for stones >3 cm in diameter, it is best to remove the gallbladder to prevent cancer. The coexistence of these diseases with stones will increase the incidence of gallbladder cancer . Symptomatic cholelithiasis Episodes of biliary colic Patients are at increased risk of complications, cholangitis, cholecystitis, AOSC, pancreatitis, gallbladder cancer Cholecystectomy should be performed.v Cholecystectomy through a right subcostal or median incision is the standard open procedure. Elective removal of the gallbladder is safe, with a mortality rate of 0.1% to 0.5%. v Cholecystectomy does not cause malnutrition and does not require postoperative dietary restriction. v Laparoscopic cholecystectomy has become an alternative option for the treatment of symptomatic cholelithiasis. v About 5% of cases undergoing laparoscopic cholecystectomy are converted to open surgery because of poor gallbladder anatomy or complications. v Patients who refuse surgery or are not candidates for surgery Gallstones can sometimes dissolve in the body after several months of oral bile acids. Stones should be uncalcified, and oral cholecystogram confirmation of normal gallbladder function is necessary for lithotripsy. Ursodeoxycholic acid 19mg/kg/day can reduce the secretion of cholesterol in the bile and decrease the cholesterol saturation in the bile, which can gradually dissolve the cholesterol-rich stones in 30%-40% of patients. It is common for gallstones to recur after stopping the medication. Is it possible to remove gallstones with bail? Yes, but there are strict requirements v Firstly, to confirm the diagnosis of gallbladder stones or gallbladder polyps, except for gallbladder stones in combination with common bile duct stones on ultrasound; secondly, to understand the function of the gallbladder, which is essential for gallbladder preservation; v Thirdly, to understand the normal wall of the gallbladder. Hepatobiliary Surgery Department, Xuanwu Hospital, Capital Medical University Hepatobiliary Specialist Clinic, 5th floor: Tuesday afternoon, 2nd floor, outpatient clinic Zheng Yamin