Many people have stones in their gallbladder and do not know it. Gallbladder stones are solid stone-like deposits formed by the precipitation of cholesterol and bile pigment calcium salts from the bile secreted by the liver. Stones in the gallbladder do not require treatment if they are asymptomatic. Many people find gallbladder stones in the abdomen during a physical examination with ultrasound, which causes anxiety and concern and may cause some symptoms thereafter, actually due to lack of understanding of gallstone disease and therefore mental stress.
Only 20% of gallbladder stones have biliary colic attacks, a severe right upper abdominal pain that is so severe and sudden that the patient can correctly recall the time of onset, such as at 10:00 a.m. or 1:00 p.m. The pain is often followed by nausea or vomiting. The pain lasts from 10 minutes to several hours. The pain is then relieved, but the patient often has a 1-2 day loss of diet.
Gallstone disease is now very common. During the three years of natural disasters in China in the late 1950s, there were few gallbladder stone inpatients in the wards, but nowadays, more than half of the abdominal surgeries in general wards are performed for cholelithiasis. Therefore, gallstone disease and diet are closely related.
If gallstone symptoms and comorbidities occur, the consequences can be very serious if not treated correctly, but timely diagnosis and treatment can lead to a rapid recovery.
I. Symptoms of gallstone disease
The symptoms of gallbladder stones are not exactly the same, but some only show chronic dyspepsia, which can include belching, nausea, nausea and mild epigastric distension. These symptoms are not specific and many other diseases can have these symptoms. For example, gastric ulcer, gastric cancer, duodenal ulcer, chronic pancreatitis, etc. Other organ diseases in the abdominal cavity can have these symptoms, and even the heart, lungs and pleura outside the abdominal cavity can also show these symptoms.
Therefore, when a patient goes to a hospital, the physician neither asks for details of the disease nor does he do a physical examination, and even prescribes or issues an ultrasound request form before the patient has finished speaking. In this way, misdiagnosis may occur. Gallbladder stones are very easy to detect and identify with ultrasound. If gallbladder stones are present, they may also be caused by other diseases. Once common gallbladder stones are found, physicians do not look deeper and blame them all on gallbladder stones.
They are even immediately hospitalized for surgery, without detailed medical history and physical examination after admission, relying on all kinds of special examinations and laboratory tests. In the past few years, I have encountered many cases with serious illnesses such as gastric cancer, hepatic hilar cholangiocarcinoma and pancreatic cancer, which were treated as gallbladder stone surgery in other hospitals and then pushed out the door after surgery, and finally entered our hospital for re-operation.
Another symptom of gallbladder stones is the sudden onset of acute colic in the upper abdomen or right upper abdomen, with a tendency to paroxysmal pain.
The abdominal pain may come on suddenly after eating or at night and last from 15 minutes to several hours. The pain starts in the upper abdomen and can move to the back. The pain starts in the upper abdomen and can be transferred to the back. After this colic disappears, there is still upper abdominal distension for 1-2 days. Episodes of colic may recur at intervals of weeks, months, or even years, but they do not occur every day.
Gallstones in the gallbladder can be expelled into the bile ducts and thereafter into the small intestine to be removed in the stool. The gallbladder can produce stones continuously, while smaller stones are often expelled naturally. If the gallbladder stones are large and their diameter exceeds that of the small bile ducts, they are not easily expelled and become lodged and cause colic. Even if you take a variety of drugs with the reputation of stone removal, it does not prove that the stones have been discharged, and stones are naturally discharged without drugs. Gallstone discharge is not a good thing, because once obstruction of the bile duct occurs, colic can occur, and even infection and fever; obstruction of the common bile duct can occur jaundice, or acute gallstone pancreatitis.
Small stones in the gallbladder can regenerate even if they are discharged, and the discharge of gallstones does not mean that the disease has been cured. Therefore, it is better to leave the gallbladder stones in the gallbladder than to expel them. Even if cholecystitis occurs as a result, the treatment is much simpler, as the gallbladder can be removed and the patient can be discharged from the hospital in a week or so after surgery. If there are stones in the bile ducts, blocking the flow of bile to the small intestine may cause infection and jaundice, and the bile ducts need to be cut open to remove the blockage, and the hospital stay can be as long as 3-6 weeks.
If biliary pancreatitis occurs, the recovery time after hospitalization is even longer, and severe gallstone pancreatitis is a fatal complication. In fact, some so-called lithotripsy drugs and methods do not have definite evidence that smaller gallbladder stones are expelled naturally, and even if they are expelled, they cannot be considered cured. If they are obstructed on the way to expulsion, complications can occur, which can be very dangerous. Therefore, once jaundice occurs in gallstone disease, i.e., yellow color of the skin and eyes, and the patient may have chills and fever, hospitalization is necessary. It should be remembered that if there is no pain, once jaundice and dark yellow urine occur, symptomatic treatment is not advisable and hospitalization is necessary to identify the cause, as it is not necessarily caused by gallstones.
II. Gallstone classification and causes
Gallstones can be as small as a fine grain of sediment or as large as a bird’s egg, garden-shaped, with a smooth or rough mulberry surface, or a multifaceted cone, and can be single or as many as hundreds. Medically gallstones are divided into three categories, namely.
1, cholesterol stones: mostly seen in Europe, America and the Middle East, relatively few in China. These stones are hard, garden-shaped, with a mulberry surface, light, and can bounce back and jump up when thrown to the ground, and can be broken only when struck with force, with shiny crystals visible on the inner surface. The source is from the gallbladder. Ultrasound examination of physical examination, often found in the gallbladder polyp 95% of the polyps are actually such cholesterol crystals deposited in the gallbladder wall, so the pseudo-polyps rather than true polyps.
True polyps should be superfluous organisms growing on the wall of the gallbladder, soft in texture. Pseudopolyp is a form of cholesterol stone, it can be dislodged in the gallbladder to form gallstones, and can also be discharged naturally through the bile ducts, which is relatively easy to discharge due to its small size, but pain can also occur when discharged.
2.Bile pigment stones: They are quite common in China and are common in Southeast Asian countries. Most of the bile pigment stones come from the gallbladder, and most of the bile pigment stones in the bile ducts are small pigment stones that are discharged from the gallbladder and then stay in the bile ducts to develop into larger stones.
3.Primary bile duct stones: These stones are also calcium bile pigment stones, which do not come from the gallbladder, but are formed in the bile duct itself, and there are often many such stones, which can exist in both intrahepatic and extrahepatic bile ducts.
The reasons for the occurrence of gallstones are not fully understood, but some of the factors that form stones are understood. They are described as follows.
1. The bile secreted by the liver contains a lot of cholesterol and is out of proportion to other components, thus it cannot be completely dissolved and microstones are precipitated, forming cholesterol stones. Especially in the gallbladder, bile is concentrated more than 4 times, which is the condition of formation. The high cholesterol content in the bile secreted by the liver is not correlated with the high cholesterol concentration in the blood, so oral medication to lower blood cholesterol will not lower the cholesterol content in the bile and cannot prevent the occurrence of gallstones.
2. Incomplete emptying of the gallbladder. After eating, the gallbladder will contract and discharge bile to the small intestine to help digestion. If the gallbladder contracts poorly or weakly, such as during pregnancy or after a long period of fasting, it will make the gallbladder contract weakly, and gallstones are likely to occur.
3.Other factors.
I. Women suffer from gallstones more than twice as much as men, because female estrogen increases cholesterol excretion in bile. Progesterone makes the gallbladder contraction force decrease, so the gallbladder stones are prone to occur after pregnancy. Oral contraceptive pills and postmenopausal hormone replacement therapy both increase cholesterol in the bile and decrease the contractility of the gallbladder, which increases the risk of gallstones. Evidence for an increased risk of gallstones is based on epidemiological and statistical analyses that show an increased incidence of gallstones, but not in all contraceptive users and pregnant women.
The increased cholesterol content in bile, the relative decrease in bile salts and the incomplete emptying of the gallbladder by contraction are all factors that increase the risk of gallstone formation in overweight and obese individuals. Women who are overweight at the age of 20-40 are 6 times more likely to suffer from gallstone disease than normal weight women.
The risk of gallstones increases with a high fat and calorie diet and with non-manual work for sedentary workers; on the contrary, a low-fat, low-calorie diet and physical exercise can reduce the occurrence of gallstones.
Ⅳ, age increases the incidence of gallstones relatively increased.
Treatment of gallstone disease
Asymptomatic gallbladder stones do not require treatment. Such gallstones are often detected by ultrasound during physical examination and are called “static” gallstones, so a wait-and-see attitude should be adopted. However, if symptoms occur and are found to be caused by gallstones, they should be treated promptly.
Surgery is the most effective and therefore the most commonly used gallstone treatment.
Surgical removal of the gallbladder removes the source of the gallstones. However, in the case of primary bile duct stones, removal of the gallbladder is not sufficient and another bile duct intestinal anastomosis is required.
It is reasonable that many patients are afraid of surgery and seek non-surgical treatment options. However, there are only two types of non-surgical treatments with proven evidence and effectiveness to date.
One is oral ursodeoxycholic acid, which is taken daily for six months and is very expensive in aggregate. The problem remains that it is limited to cholesterol stones and is only effective for single stones less than 1.5 cm in diameter, otherwise it is ineffective; half of those whose gallstones disappear completely within 10 years after stopping the drug will have a recurrence of gallstones.
This drug can dissolve cholesterol stones in the gallbladder, so it was considered a good drug and a great invention when it was first used 20 years ago, but it is rarely used after a long time. There are many other commercially available bile acid drugs that do not have this litholytic effect, but still claim to treat gallstones. Ursodeoxycholic acid is also useless in the case of calcium bile pigment stones and primary bile duct stones.
Another non-surgical treatment for gallbladder stones is to use extracorporeal ultrasound to focus on the gallstones and then break them up. If the gallstones in the gallbladder are large, they are not easily broken, and even if they are broken, they are not easily expelled and there is a risk of injury to adjacent normal tissues. Therefore, it is only used in combination with oral ursodeoxycholic acid in cases of cholesterol stones, which was popular for a while more than 10 years ago, but it has not stood the test of history.
In addition to removing the source of the gallstones, 95% of gallbladders with symptomatic gallstones have varying degrees of acute and chronic inflammation, or other problems with gallbladder contraction or bile concentration. In most gallbladder stones, the gallbladder is no longer functional, and removal of a non-functional gallbladder does not impede digestive function, so only some cases have a slight increase in stool frequency after surgery, but they return to normal after a few months.
Primary bile duct stones and gallstones draining from the gallbladder into the bile duct without access to the small intestine require surgical treatment. In addition to the onset of colic, this condition is associated with acute cholangitis infection, chills and fever and jaundice, which can be very dangerous for the liver and the whole body. In a few cases, the bile ducts can be removed with a duodenoscopic electrodissection at the protrusion of the bile ducts into the small intestine, followed by trapping of the gallstones; in most cases, the gallstones are too large and numerous to be removed, especially in primary bile duct stones. If there are stones in the intrahepatic bile ducts and they cause symptoms of infection, a biliary-intestinal anastomosis should be performed.
Isolated small stones in the intrahepatic bile ducts found by ultrasound during physical examination are not indicated for surgical treatment if they are asymptomatic.
In conclusion, cholelithiasis is a common and complex disease, and a short description is not enough to give a complete picture. In terms of surgery, there are laparoscopic and open surgery, each with its own surgical indications, which are not substitutes but rather complementary. This will be addressed in a separate article.