Gallstone disease is a very common disease in the Beijing area, and we see many people holding jars of medicine and drinking them every day and seeking medical help. According to statistics, about 10% of adults suffer from gallstone disease, and in middle-aged women, the incidence is even as high as 15%. At present, gallstone disease accounts for more than 60% of hepatobiliary surgery in hospitals, and the age of onset is characterized by a younger trend and familial distribution. Gallstone disease is a disease in which stones occur in any part of the biliary system (including the gallbladder and intra- and extrahepatic bile ducts). The causes, types and components of gallbladder stones and primary hepatic bile duct stones vary, and their clinical manifestations are also very different. If not treated early, they often cause serious complications, such as septic infection, chronic inflammation, obstructive jaundice, pancreatitis, etc., or even life-threatening damage to the liver and cancer.
A. What factors are associated with gallstone disease
(A) Gallbladder stones
Most of the gallbladder stones are cholesterol stones, which are hard in texture. Etiological studies and epidemiological surveys show that the occurrence of gallbladder stones is related to the following factors.
1. age and gender: they are rare in adolescents, and the incidence in adults increases with age, with a high incidence at the age of 50-59. The incidence of gallbladder stones is more common in women, and the ratio of male to female incidence is about 1:2.57.
2, diet: the increase in the intake of animal fat, protein and fine carbohydrates, and the decrease in the intake of fiber food can lead to an increase in the incidence of gallbladder stones. Due to the change of dietary structure of our population, the incidence of gallbladder stones in gallstone disease has increased from 52.8% to 79.9% 20 years ago. A family’s dietary habits are basically the same, so gallbladder stones often suffer from one family to another.
3, obesity: a study found that people who are more than 20% overweight have a nearly 2 times higher risk of gallstones than those who are less than 10% overweight.
4, disease and drugs: gallstones are associated with certain diseases, such as sickle cell anemia, thalassemia, diabetes and liver cirrhosis. Some studies have reported that certain drugs can promote gallstone formation, such as thiazide diuretics, estrogen and oral contraceptive drugs.
5, abnormal gallbladder contraction function: pregnant women, elderly people, people who have undergone gastrointestinal surgery, people who often skip breakfast, etc., due to liver metabolic disorders or biliary tract malfunction, resulting in the precipitation of solid components in the bile and the formation of stones in the gallbladder where the bile flow rate is slow and bile concentration is high. Gallstones are as small as a grain of rice or even as large as a walnut, and can be one, many, or up to several thousand grains. Generally, once stones are formed, they will accumulate more and more and grow bigger and bigger.
6, other causes: hyperlipidemia of lipid metabolism disorders, chronic inflammation of the gallbladder and genetic factors, etc.
(B) Primary bile duct stones
Stones that do not fall into the bile ducts from the gallbladder but grow in the bile ducts are called primary bile duct stones, including stones in the intrahepatic bile ducts and extrahepatic bile ducts, mostly soft calcium bilirubin stones, which are often called “sediment-like” stones. The main cause is biliary tract infection, which can lead to biliary tract infection, biliary tract obstruction, bile stagnation, poor excretion, resulting in the formation of stones in the intrahepatic and extrahepatic bile ducts. Many patients have had biliary roundworms or other parasites in childhood, and the worms die in the bile ducts, forming stones with the remains of the roundworms as the core. Therefore, primary bile duct stones are mostly found in patients in rural areas and remote areas with poor sanitary conditions. In recent years, due to the improvement of living conditions, primary cholesterol stones with a harder texture like those in the gallbladder have also been seen in the bile ducts, and the reasons for this are still being studied in depth.
What are the manifestations of cholelithiasis?
More than half of the patients with gallstone disease, especially gallbladder stones, are occult gallbladder stones, which may have no obvious symptoms for a long time and are detected by ultrasound during routine physical examination. Many patients only show a vague pain or fullness in the “heart pit” area, have eructations, poor digestion and cannot eat fatty food, and are treated as stomach problems for a long time. The symptoms only become apparent when the bile duct becomes infected and inflamed or when a stone becomes lodged. Many patients with gallstone attacks are misdiagnosed as angina pectoris or coronary heart disease. For example, if a small gallbladder stone gets stuck in the thin caliber of the bile duct after a full meal or exertion, or if a stone falls into the common bile duct and gets stuck, it can cause quite severe epigastric pain, which can cause pain in the back and right shoulder, and is often accompanied by nausea and frequent dry vomiting, and in some cases, the pain is so severe that it is “deadly”, which is commonly known as biliary This is commonly known as biliary colic. In severe cases, septicemia, perforation, chills and high fever, peripheral jaundice, pancreatitis, etc. may even occur and threaten life.
If intrahepatic bile duct stones are combined with extrahepatic bile duct stones, the manifestations are similar to those of extrahepatic bile duct stones caused by gallbladder stones falling into the bile duct, i.e., epigastric pain, chills and high fever and jaundice may occur. In the absence of extrahepatic bile duct stones, the patient may be asymptomatic for many years or may only have distension and discomfort in the liver and chest and back, and loss of appetite. If infection occurs, chills or high fever may occur. Unless the stones block the mouth of bile leaving the liver and cause obstruction, no significant jaundice usually occurs. When there are frequent episodes of cholangitis in the near future, accompanied by progressive jaundice, abdominal pain and fever that are difficult to control, as well as symptoms such as weight loss, especially if the doctor is over 50 years old, the possibility of combined bile duct cancer should be suspected.
Can we take medicine to dissolve the stones or use medicine or extracorporeal ultrasonic lithotripsy to excrete the gallstones?
For primary bile pigment stones in the intra- and extra-hepatic bile ducts, there are no drugs for stone dissolution and stone removal. As for cholesterol stones in the gallbladder, there are some drugs in use, but the efficacy is not promising. Ursodeoxycholic acid, which has the most definite efficacy and relatively low toxicity, can completely disappear in about 10%-30% of patients if the drug is taken for one year, but it is time-consuming and expensive, and the drug is quite toxic, and what is more troublesome is that once the drug is stopped, the gallstones will reappear in most patients, making the previous treatment wasted.
In the biliary system, the gallbladder is like a bile storage reservoir and the common bile duct is the main exit channel for bile discharge. Each episode of biliary colic can be described as the body’s own reflex mechanism trying to expel, or squeeze out, the gallstones. Where to squeeze it out? Squeezed into the bile duct. Sometimes we see some patients after several episodes of biliary colic, the stone is luckily squeezed out from the bile duct and expelled with the stool, but this is something that can only happen. Because of the narrow opening of the bile duct, it is more common for the stone to get stuck here and not be expelled, which can lead to serious problems such as more severe abdominal pain, high fever and jaundice, and even sepsis, shock, and death. It is clear that patients should never take drugs to remove stones, as this will only backfire and lead to more trouble.
Patients often ask if extracorporeal ultrasonic lithotripsy can be used for gallbladder stones. It is true that this is a new treatment method. If there is no chronic inflammation of the gallbladder and the gallbladder is still functional, after an average of 1 to 2 years of treatment, most patients can have their stones broken and expelled from the body, and about half of the patients can have their stones removed. However, after stopping the treatment, many patients will have a recurrence of gallbladder stones. Moreover, during the process of stone removal, there is always a risk of the stones falling into the bile ducts and not being discharged, so this method should be used carefully, weighing the pros and cons.
Fourth, what if only the stones are removed and the gallbladder is preserved? If the gallbladder is removed, will the bile ducts grow stones? What is the harm of removing the gallbladder?
The surgery of cutting a small opening in the gallbladder, removing the stone with a choledochoscope or removing the stone directly with a clamp, and then sewing up the incision to preserve the gallbladder is the oldest means of treating gallstones, which is gradually replaced by cholecystectomy due to the recurrence of stones and many disadvantages. The gallbladder can be selected if the gallbladder is functional, while chronic inflammation of the gallbladder should be treated with caution. Since there are two underlying causes of gallbladder stones: one is a problem with liver metabolism, which produces bile that is prone to stone formation; the other is a problem with the gallbladder itself. We do not have a reliable treatment for these two problems yet, so even if the stones are removed from the gallbladder, new stones may grow in a short time. This is why cholecystectomy is the most reliable means of treating gallbladder stone disease.
There is no scientific basis for the claim that stones will grow in the bile ducts after the gallbladder has been removed. The truth is that keeping a gallbladder with stones increases the chance of bile duct stones. In many patients with bile duct stones, the stones fall out of the gallbladder. So why do some patients find bile duct stones again some time after cholecystectomy? Possible reasons are: secondary common bile duct stones were not found to be present at the same time as the gallbladder was removed; the patient’s common bile duct stones did come out de novo. This is a relatively rare occurrence. However, one thing is certain, removing the gallbladder with stones will only reduce the risk of growing stones in the bile duct.
It is generally considered that the patient should go for cholecystectomy when the danger of keeping the diseased, stone-bearing gallbladder outweighs the benefit of the gallbladder’s physiological function to the body. After removal of the gallbladder, the digestive function of the person will be affected for a short period of time due to the loss of the gallbladder’s function of storing bile, but the effect is not significant. The majority of patients will gradually adapt and will not feel any abnormalities. From the clinical point of view, those with mild or even no symptoms of gallbladder stones before surgery and those with basically normal gallbladder function before surgery are prone to such digestive malfunction after surgery; while those with heavy symptoms before surgery and those whose gallbladder has lost its normal function, their digestive function will improve after surgery.
V. Is it better to perform cholecystectomy by perforation
Perforation surgery is the common name of laparoscopic cholecystectomy, which is an emerging surgical procedure in the 1990s. It is not different from the traditional open-incision cholecystectomy in essence, the only difference is that the open incision is smaller, and the patient recovers quickly and with less pain, so it is popular among patients. It can be said that the majority of patients can have their gallbladder removed by this method. However, the decision of which method is suitable for each patient should be made by the doctor. Generally speaking, laparoscopic cholecystectomy is still not as safe as open surgery in terms of safety and indications, especially for patients with complex gallbladder stones and biliary comorbidities, and open surgery is still safer.
Must intrahepatic bile duct stones be treated with early surgery?
The intrahepatic bile ducts are like the relationship between a small river and a large river, with a dendritic distribution, and the small bile ducts merge into the large bile ducts. Generally, in order to grow stones in the liver, most of the bold ducts have inflammatory stenosis, so that the bile excretion in the small bile ducts is impaired, and stones slowly accumulate in the ducts. Therefore, surgery is the fundamental method to cure intrahepatic bile duct stones.
The presence of stones in the intrahepatic bile ducts will cause repeated infections and inflammation in the bile ducts, which will eventually destroy the normal structure of the liver tissue and lead to serious complications, such as fibrosis and atrophy of the liver tissue, cirrhosis, abscess formation in the liver, and cancer, which can only be treated by liver transplantation. Therefore, the earlier the intrahepatic stone disease is operated, the better the results and the less difficult the surgery. The specific surgical methods include hepatic lobectomy, bile duct reconstruction, hepatic intestinal anastomosis, etc., which should be chosen by the doctor according to the specific situation.
Seven, how to prevent gallstone disease
Pay attention to dietary hygiene, food should be light, less greasy and fried food. Keep the bowels open, the six internal organs to pass for use, liver and gallbladder damp heat, constipation when the symptoms are aggravated, it is important to keep the bowels open. To change the sedentary lifestyle, more walking, more exercise. To nourish sex, long-term family disharmony, mood can trigger or aggravate the disease, to be broad-minded, relaxed mood.