I. Introduction of gallstone disease
Gallstone disease is a common disease in China, gallstone Chinese medicine alias dystocia, biliary distension, to the right upper abdominal distension or pain, examination found gallbladder or bile duct stones as the main manifestation of the stone type of disease. It often coexists with bile disease or biliary distension. Gallstone disease in Western medicine is a disease of spontaneous stone formation in the biliary system (bile ducts, gallbladder). Its clinical manifestations depend on whether the stones cause biliary obstruction and the site and degree of obstruction and whether they are co-infected. Stones are formed when certain components of bile (cholesterol, bile pigments, calcium, mucus, etc.) precipitate and coalesce in the bile ducts under the action of various factors. Depending on the composition of the stones, there are cholesterol, bile pigment and mixed stones, which can occur in the gallbladder, intrahepatic bile duct and common bile duct. The prevalence of gallstone disease is influenced by race, ethnicity, genetics, geography, diet, and behavior. In 1989, the ultrasound survey of 102,600 people in China showed a prevalence of about 6.27%, and in 1992, epidemiological studies showed a dramatic increase in the number of gallstone patients, with a twofold increase compared to a decade earlier. The incidence of cholelithiasis has always varied widely throughout the world, and the types of stones vary. The prevalence in our population is 9-10%, with a natural population incidence of 7.8%. Surveys have shown that the admission rate of patients with cholelithiasis accounts for about l.5% of hospitalized patients in the same period, and the incidence is increasing year by year. With the improvement of living standard and the change of dietary structure, the incidence of cholelithiasis (especially cholesterol stones) will remain high and even increase rapidly. Gallstone disease has been described as a “4F” disease, i.e. Female, Forty, Fertile and Fat, which depicts the high-risk group for the disease. Initially this was a clinical impression, which has since been confirmed by many epidemiological studies. In conclusion, there are numerous risk factors for cholelithiasis in China, which are summarized as follows: individual factors, ethnic and family aggregation, behavioral factors, pharmacological factors, dietary factors, female factors, etc.
Clinical manifestations and diagnostic methods of cholelithiasis
(A) Clinical manifestations of gallstone disease
Gallstones in the “quiescent phase” (i.e., the period without biliary obstruction and infection) may have no obvious symptoms and signs, or may only show some non-specific gastrointestinal symptoms, such as dull pain in the liver or epigastric region, aversion to greasy food, acidity, belching, heartburn, premature beats, back pain, hypertension, abdominal distension, etc. The symptoms of “indigestion” or “chronic gastric disease”.
When stones block the bile duct or secondary infection, more typical clinical symptoms will appear, because stones block the biliary system and seriously affect the normal secretion of bile. When stones block the biliary system, the normal secretion, storage and release of bile will be seriously affected, resulting in severe abdominal pain, bloating, fever, inflammation and other symptoms, nausea and even vomiting when seeing or thinking of greasy food.
I. Gallbladder stones
About half of the patients can be asymptomatic for life, called occult gallbladder stones. Usually, for larger gallbladder stones, patients have digestive symptoms such as stuffy discomfort in the upper or right side of the abdomen, belching, and aversion to greasy food. In severe cases, due to inflammatory exudation or gallbladder perforation leading to limited or diffuse peritonitis, signs of peritoneal irritation may appear. If stones obstruct the gallbladder duct for a long time without infection, only gallbladder fluid may form and there may be no clinical symptoms, and a distended gallbladder may be found on physical examination of the abdomen. If the stone is discharged into the common bile duct, it may cause biliary colic, obstructive jaundice, purulent cholangitis, or even hemorrhagic necrotizing pancreatitis due to stone entrapment in the bile duct. In the case of secondary infection, signs such as pressure pain, muscle tension and rebound pain may appear in the right upper abdomen.
Common bile duct stones
The symptoms are atypical during the non-episode period and are easily confused with ulcer disease and indigestion. When the stones cause bile duct obstruction resulting in dilatation of intrahepatic bile ducts and poor bile drainage, local and systemic symptoms may appear. About 75% of patients have epigastric or right upper abdominal paroxysmal colic, followed by jaundice in about 70% of patients. If the stone obstructs the bile duct and is combined with biliary tract infection, the triad of abdominal pain, chills and high fever and jaundice may occur simultaneously. If the bile duct obstruction and infection are not relieved and the infection is not controlled, systemic toxic symptoms such as decreased blood pressure and mental disturbance (Reynold’s pentad) may occur, which is called acute obstructive purulent cholangitis. Signs in patients with common bile duct stones are usually subxiphoid right pressure pain.
(B) Diagnostic methods of gallstone disease
1 Chinese medicine identification criteria
Chinese medicine classification:
Qi stagnation syndrome
Symptoms: distension and vague pain in the right upper abdomen, or paroxysmal colic, pain leading to the shoulder and back, or with fullness in the stomach and epigastric region, aversion to greasy food, light red tongue, white or slightly yellow tongue coating, thin or tight pulse.
Analysis of the symptoms: Gallstone blockage, loss of liver circulation and obstruction of the ducts, therefore, the right upper abdomen is distended and full with vague pain, or paroxysmal colic, with pain leading to the back of the shoulder; liver qi reverses, often invading the spleen and stomach, with abnormal transportation and transformation, therefore, the stomach and epigastric region is full, with anorexia of greasy food; the pulse is string is a sign of liver depression.
Damp-heat evidence
Symptoms: Pain in the right upper abdomen, with paroxysmal intensification, or even unbearable colic, leading to the shoulder and back, with a feeling of heaviness. High fever and chills, bitter mouth and dry throat, nausea and vomiting, or yellow sclera, yellow urine, constipation, pressure pain in the right upper abdomen, and in severe cases, muscle tension and refusal to press, sometimes the enlarged gallbladder can be touched. The tongue is red, the coating is yellow and greasy, and the pulse is stringy or slippery.
Analysis of the symptoms: Damp-heat gallstones are embedded in the liver and gallbladder, the liver ligament is out of harmony, and if it does not pass, it is painful. If damp-heat is injected into the bladder, the urine is yellow; if damp-heat is contained in the intestines and stomach, the Qi is blocked and the internal Qi is not open, the stool is constipated; the tongue is red, the moss is yellow and greasy, and the pulse is stringy or slippery.
Purulent evidence
Symptoms: severe pain in the right hypochondrium, abdominal distension and fullness, refusal to press, chills and high fever, or cold and fever, bitterness in the mouth and dryness in the throat, yellow staining of the body and eyes, or even delirium, coldness in the extremities, red and vivid tongue, yellow and dry coating, slippery pulse.
Analysis of the symptoms: The disease is in the liver and gallbladder, stone obstruction, liver stagnation, qi stagnation, pain if not pass, therefore, severe pain in the right side, abdominal distension and fullness, refusal to press, damp-heat with toxicity, heat and toxicity.
2 Diagnostic criteria in Western medicine
(1) Diagnostic criteria for gallbladder stones
① Symptoms of right upper abdominal distension and discomfort or chronic cholecystitis.
② Non-essential specific signs of right upper abdominal pressure pain and muscle tension.
③ B ultrasound shows strong light group with sound shadow in the gallbladder, which can move with the direction of body position.
The diagnosis can be made by having items ① to ③.
(2) Diagnostic criteria for extrahepatic bile duct stones
① Recurrent episodes of right upper abdominal paroxysmal colic.
② Deep pressure pain and muscle tension in subxiphoid and right upper abdomen.
③ B ultrasound shows a light mass with acoustic shadow in the common bile duct, and the bile ducts above the light mass have different degrees of dilatation. Percutaneous hepatic cholangiogram can show the stone shadow in the common bile duct.
The presence of items ① to ③ can be confirmed.
(3) Diagnostic criteria for intrahepatic bile duct stones
① Recurrent episodes of right upper abdominal distension and pain, chills, and history of high fever.
② Asymmetric enlargement of the liver with pressure pain and percussion pain in the liver area.
③ B ultrasound indicates dilated intrahepatic bile ducts with strong light mass with acoustic shadow inside.
④ Percutaneous hepatic cholangiography or retrograde cholangiopancreatography with transduodenal fiberoptic endoscopy showed intrahepatic bile duct stenosis and dilated lesions with stone shadows of different sizes in the dilated bile ducts.
The diagnosis can be made with items ① to ③, and the diagnosis can be confirmed with item ④.