Picture, Symptoms, Types, Causes, Risks, Treatments

Written by WebMD Editorial Contributors

• What Are Gallstones?
• Gallstone Types
• Symptoms of Gallstones
• Causes of Gallstones
• Gallstone Risk Factors
• Gallstone Diagnosis
• Can Gallstones Go Away on Their Own?
• Gallstone Treatment
• Complications of Gallstones
• Preventing Gallstones
• More

Gallstones are pieces of solid material that form in your gallbladder, a small organ under your liver. If you have them, you might hear your doctor say you have cholelithiasis.

Your gallbladder stores and releases bile, a fluid made in your liver, to help in digestion. Bile also carries wastes like cholesterol and bilirubin, which your body makes when it breaks down red blood cells. These things can form gallstones.

Gallstones can range in size from a grain of sand to a golf ball. You might not know that you have them until they block a bile duct, causing pain that needs treatment right away.

The two main kinds of gallstones are:

• Cholesterol stones. These are usually yellow-green. They’re the most common, making up 80% of gallstones.
• Pigment stones. These are smaller and darker. They’re made of bilirubin.

Gallstones don’t normally cause symptoms. Symptoms occur only when a gallstone gets stuck and blocks the flow of bile through your system.

If you have symptoms, they may include:

• Pain in your upper belly, often on the right, just under your ribs
• Pain in your right shoulder or back
• An upset stomach
• Vomiting
• Other digestive problems, including indigestion, heartburn, and gas

See your doctor or go to the hospital if you have signs of a serious infection or inflammation:

• Belly pain that lasts several hours or is severe
• Fever and chills
• Yellow skin or eyes

Doctors aren’t sure exactly what causes gallstones, but they might happen when:

• There’s too much cholesterol in your bile. Your body needs bile for digestion. It usually dissolves cholesterol. But when it can’t do that, the extra cholesterol might form stones.
• There’s too much bilirubin in your bile. Conditions like cirrhosis, infections, and blood disorders can cause your liver to make too much bilirubin.
• Your gallbladder doesn’t empty all the way. This can make your bile very concentrated.

You’re more likely to get gallstones if you:

• Have a family history of them
• Are a woman
• Are over age 40
• Are of Native American or Mexican descent
• Are obese
• Have a diet high in fat and cholesterol but low in fiber
• Don’t get much exercise
• Use birth control pills or hormone replacement therapy
• Are pregnant
• Have diabetes
• Have an intestinal disease like Crohn’s
• Have hemolytic anemia or cirrhosis of the liver
• Take medicine to lower your cholesterol
• Lose a lot of weight in a short time
• Are fasting

Your doctor will do a physical exam and might order tests including:

Blood tests.  These check for signs of infection or blockage, and rule out other conditions.

Ultrasound. This makes images of the inside of your body.

CT scan. Specialized X-rays let your doctor see inside your body, including your gallbladder.

Magnetic resonance cholangiopancreatography (MRCP). This test uses a magnetic field and pulses of radio waves to make pictures of the inside of your body, including your liver and gallbladder.

Cholescintigraphy (HIDA scan). This test can check whether your gallbladder squeezes correctly. Your doctor injects a harmless radioactive material that makes its way to the organ. A technician can then watch its movement. This can help diagnose cholecystitis (inflammation of the gallbladder) from gallstones.

Endoscopic retrograde cholangiopancreatography (ERCP). Your doctor runs a tube called an endoscope through your mouth down to your small intestine. They inject a dye so they can see your bile ducts on a camera in the endoscope. They can often take out any gallstones that have moved into the ducts, but that’s only done if treatment is planned as part of the procedure since it’s invasive.

Endoscopic ultrasound. This test combines ultrasound and endoscopy to look for gallstones that may be in places that are hard to see with other imaging, such as in the common bile duct as it passes through the pancreas.

If your gallstones aren’t causing symptoms, there’s usually no need for you to have surgery. You’ll only need it if a stone goes into, or blocks, one of your bile ducts. This causes what doctors call a “gallbladder attack.” It’s an intense, knife-like pain in your belly that can last several hours.

If you have sickle cell or another blood disorder, your doctor may consider doing a cholecystectomy as a precaution, even if you don’t have symptoms. 

You don’t need treatment if you don’t have symptoms. Some small gallstones can pass through your body on their own.

Most people with gallstones have their gallbladders taken out. You can still digest food without it. Your doctor will use one of two procedures.

Laparoscopic cholecystectomy. This is the most common surgery for gallstones. The surgeon works through tiny cuts (incisions). They pass a narrow tube called a laparoscope into your belly through a small cut. The tube contains a tiny light and a camera. The doctor will take out your gallbladder through another small cut using special devices. You’ll usually go home the same day.

Open cholecystectomy. Your doctor makes bigger cuts in your belly to remove your gallbladder. You’ll stay in the hospital for a few days afterward. You’ll need open surgery if you have a bleeding disorder. You may also need it if you have severe gallbladder disease, are very overweight, or are in your last trimester of pregnancy.

For both types of surgery,  you’ll get general anesthesia. This means you won’t be awake during the procedure.

If gallstones are in your bile ducts, your doctor may use ERCP to find and remove them before or during surgery.

Nonsurgical treatment: If you have another medical condition and your doctor thinks you shouldn’t have surgery, they might give you medication instead. Chenodiol (Chenodo l) and ursodiol (Actigall, Urso 250, Urso Forte) dissolve cholesterol stones. They can cause mild diarrhea.

You may have to take the medicine for years to totally dissolve the stones, and they may come back after you stop taking it.

Gallstones can cause serious problems, including:

• Gallbladder inflammation (acute cholecystitis). This happens when a stone blocks your gallbladder so it can’t empty. It causes constant pain and fever. Your gallbladder might burst, or rupture, if you don’t get treatment right away.
• Blocked bile ducts. This can cause fever, chills, and yellowing of your skin and eyes (jaundice). If a stone blocks the duct to your pancreas, that organ may become inflamed (pancreatitis).
• Infected bile ducts (acute cholangitis). A blocked duct is more likely to get infected. If the bacteria spread to your bloodstream, they can cause a dangerous condition called sepsis.
• Gallbladder cancer. It’s rare, but gallstones raise your risk of this kind of cancer.

Some lifestyle changes might lower your risk of gallstones.

• Eat a healthy diet that’s high in fiber and good fats, like fish oil and olive oil. Avoid refined carbs, sugar, and unhealthy fats.
• Get regular exercise. Aim for at least 30 minutes, 5 days a week.
• Although obesity is a risk factor, avoid diets that make you lose a lot of weight in a short time.
• If you’re a woman at high risk of gallstones (for example, because of your family history or another health condition), talk to your doctor about whether you should avoid using hormonal birth control.

Top Picks

Picture, Symptoms, Types, Causes, Risks, Treatments

Written by WebMD Editorial Contributors

• What Are Gallstones?
• Gallstone Types
• Symptoms of Gallstones
• Causes of Gallstones
• Gallstone Risk Factors
• Gallstone Diagnosis
• Can Gallstones Go Away on Their Own?
• Gallstone Treatment
• Complications of Gallstones
• Preventing Gallstones
• More

Gallstones are pieces of solid material that form in your gallbladder, a small organ under your liver. If you have them, you might hear your doctor say you have cholelithiasis.

Your gallbladder stores and releases bile, a fluid made in your liver, to help in digestion. Bile also carries wastes like cholesterol and bilirubin, which your body makes when it breaks down red blood cells. These things can form gallstones.

Gallstones can range in size from a grain of sand to a golf ball. You might not know that you have them until they block a bile duct, causing pain that needs treatment right away.

The two main kinds of gallstones are:

• Cholesterol stones. These are usually yellow-green. They’re the most common, making up 80% of gallstones.
• Pigment stones. These are smaller and darker. They’re made of bilirubin.

Gallstones don’t normally cause symptoms. Symptoms occur only when a gallstone gets stuck and blocks the flow of bile through your system.

If you have symptoms, they may include:

• Pain in your upper belly, often on the right, just under your ribs
• Pain in your right shoulder or back
• An upset stomach
• Vomiting
• Other digestive problems, including indigestion, heartburn, and gas

See your doctor or go to the hospital if you have signs of a serious infection or inflammation:

• Belly pain that lasts several hours or is severe
• Fever and chills
• Yellow skin or eyes

Doctors aren’t sure exactly what causes gallstones, but they might happen when:

• There’s too much cholesterol in your bile. Your body needs bile for digestion. It usually dissolves cholesterol. But when it can’t do that, the extra cholesterol might form stones.
• There’s too much bilirubin in your bile. Conditions like cirrhosis, infections, and blood disorders can cause your liver to make too much bilirubin.
• Your gallbladder doesn’t empty all the way. This can make your bile very concentrated.

You’re more likely to get gallstones if you:

• Have a family history of them
• Are a woman
• Are over age 40
• Are of Native American or Mexican descent
• Are obese
• Have a diet high in fat and cholesterol but low in fiber
• Don’t get much exercise
• Use birth control pills or hormone replacement therapy
• Are pregnant
• Have diabetes
• Have an intestinal disease like Crohn’s
• Have hemolytic anemia or cirrhosis of the liver
• Take medicine to lower your cholesterol
• Lose a lot of weight in a short time
• Are fasting

Your doctor will do a physical exam and might order tests including:

Blood tests.  These check for signs of infection or blockage, and rule out other conditions.

Ultrasound. This makes images of the inside of your body.

CT scan. Specialized X-rays let your doctor see inside your body, including your gallbladder.

Magnetic resonance cholangiopancreatography (MRCP). This test uses a magnetic field and pulses of radio waves to make pictures of the inside of your body, including your liver and gallbladder.

Cholescintigraphy (HIDA scan). This test can check whether your gallbladder squeezes correctly. Your doctor injects a harmless radioactive material that makes its way to the organ. A technician can then watch its movement. This can help diagnose cholecystitis (inflammation of the gallbladder) from gallstones.

Endoscopic retrograde cholangiopancreatography (ERCP). Your doctor runs a tube called an endoscope through your mouth down to your small intestine. They inject a dye so they can see your bile ducts on a camera in the endoscope. They can often take out any gallstones that have moved into the ducts, but that’s only done if treatment is planned as part of the procedure since it’s invasive.

Endoscopic ultrasound. This test combines ultrasound and endoscopy to look for gallstones that may be in places that are hard to see with other imaging, such as in the common bile duct as it passes through the pancreas.

If your gallstones aren’t causing symptoms, there’s usually no need for you to have surgery. You’ll only need it if a stone goes into, or blocks, one of your bile ducts. This causes what doctors call a “gallbladder attack.” It’s an intense, knife-like pain in your belly that can last several hours.

If you have sickle cell or another blood disorder, your doctor may consider doing a cholecystectomy as a precaution, even if you don’t have symptoms. 

You don’t need treatment if you don’t have symptoms. Some small gallstones can pass through your body on their own.

Most people with gallstones have their gallbladders taken out. You can still digest food without it. Your doctor will use one of two procedures.

Laparoscopic cholecystectomy. This is the most common surgery for gallstones. The surgeon works through tiny cuts (incisions). They pass a narrow tube called a laparoscope into your belly through a small cut. The tube contains a tiny light and a camera. The doctor will take out your gallbladder through another small cut using special devices. You’ll usually go home the same day.

Open cholecystectomy. Your doctor makes bigger cuts in your belly to remove your gallbladder. You’ll stay in the hospital for a few days afterward. You’ll need open surgery if you have a bleeding disorder. You may also need it if you have severe gallbladder disease, are very overweight, or are in your last trimester of pregnancy.

For both types of surgery,  you’ll get general anesthesia. This means you won’t be awake during the procedure.

If gallstones are in your bile ducts, your doctor may use ERCP to find and remove them before or during surgery.

Nonsurgical treatment: If you have another medical condition and your doctor thinks you shouldn’t have surgery, they might give you medication instead. Chenodiol (Chenodo l) and ursodiol (Actigall, Urso 250, Urso Forte) dissolve cholesterol stones. They can cause mild diarrhea.

You may have to take the medicine for years to totally dissolve the stones, and they may come back after you stop taking it.

Gallstones can cause serious problems, including:

• Gallbladder inflammation (acute cholecystitis). This happens when a stone blocks your gallbladder so it can’t empty. It causes constant pain and fever. Your gallbladder might burst, or rupture, if you don’t get treatment right away.
• Blocked bile ducts. This can cause fever, chills, and yellowing of your skin and eyes (jaundice). If a stone blocks the duct to your pancreas, that organ may become inflamed (pancreatitis).
• Infected bile ducts (acute cholangitis). A blocked duct is more likely to get infected. If the bacteria spread to your bloodstream, they can cause a dangerous condition called sepsis.
• Gallbladder cancer. It’s rare, but gallstones raise your risk of this kind of cancer.

Some lifestyle changes might lower your risk of gallstones.

• Eat a healthy diet that’s high in fiber and good fats, like fish oil and olive oil. Avoid refined carbs, sugar, and unhealthy fats.
• Get regular exercise. Aim for at least 30 minutes, 5 days a week.
• Although obesity is a risk factor, avoid diets that make you lose a lot of weight in a short time.
• If you’re a woman at high risk of gallstones (for example, because of your family history or another health condition), talk to your doctor about whether you should avoid using hormonal birth control.

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Cholelithiasis, surgery to remove gallbladder stones price in SP

A chronic disease of the biliary tract, in which stones form in the gallbladder (more often) and bile ducts, is called cholelithiasis (GSD).

If stones are detected in the common bile duct, then this form of gallstone disease is called choledocholithiasis .

Historical information

The disease has been known since ancient times. For the first time, gallbladder stones were discovered during the autopsy and described by Galen, the great surgeon, writer and philosopher, who lived in the second half of the 2nd century AD in ancient Rome. During the Renaissance, in the writings of Gentile de Foligno in 1341, there is also a mention of CL.

A detailed description of gallbladder stones appeared in the middle of the 18th century (C. Galeati), and at the same time, the study of their chemical composition was first undertaken. All information about cholelithiasis contained in the works of various authors was summarized by Albrecht Haller (1755). In his works, he showed that gallstones are found not only in humans, but also in horses, pigs, cows, marmots, monkeys and other animals.

He divided all stones of the gallbladder and ducts into 2 groups:

• Large ovoid, often solitary, consisting of “a tasteless yellow substance which, when heated, melts like sealing wax and is liable to burn”.
• Smaller, dark-colored, multifaceted, which are often found not only in the gallbladder, but also in the bile ducts.

Since the middle of the 19th century, there have been various theories of the origin of gallstones. Of these, two main directions can be distinguished.

Supporters of one of them saw the cause of cholelithiasis in an abnormal state of the liver. Such a liver produces bile of a changed composition, as a result of which its dense parts precipitate, forming stones. Other researchers considered bile stasis and inflammation of the biliary tract and gallbladder as the main cause of the disease.

More thorough work on GSD appeared already in the 20th century. In addition to a detailed study of the structure of gallstones, a theory of the occurrence of cholelithiasis was developed. It was based on the concept of “stagnant gallbladder” and metabolic disorders.

The incidence of gallstone disease

The incidence of gallstone disease has increased dramatically in the last decade and continues to increase. According to the National Institutes of Health (1992), 10-15% of the adult population of the world suffers from gallstone disease. Visiting doctors for bile duct and gallbladder stones in the Russian Federation is approximately 1 million people a year.

Women get sick 3-5 times more often than men, and cholelithiasis was also more common in them (5-6 times) than in men.

Modern understanding of the causes leading to gallstones

• First of all, it is a metabolic disorder that affects the chemical composition of bile. The composition of bile, which is a complex chemical solution, includes poorly soluble substances. In order for them not to precipitate, it is necessary to preserve them in strict proportions. If their percentage is violated in one direction or another, then a precipitate forms, which can then turn into stones.
• Secondly, this is a violation of the correct movement of bile along the bile ducts . The occurrence of obstacles to the outflow of bile into the duodenum, long periods of starvation lead to stagnation of bile in the gallbladder, its thickening and precipitation.

In turn, the formation of stones contributes to the disruption of the normal process of digestion: there are failures in the formation, storage and secretion of bile, which is one of the most important components for proper digestion of food. There are groups of people who are at high risk of gallstone disease and chronic calculous cholecystitis.

The following risk factors are distinguished:

• Heredity . The likelihood of developing gallbladder and duct stones increases in the presence of direct relatives suffering from this pathology.
• Diseases associated with metabolic disorders: diabetes mellitus, gout, obesity, atherosclerosis, decreased thyroid function.
• Diseases of the liver : cirrhosis, fatty liver, chronic hepatitis.
• Diseases of the digestive system eg pancreatitis, duodenitis, colitis, dysbacteriosis and others. Sometimes there is the so-called “Saint’s triad” – a combination of cholelithiasis with diaphragmatic hernia and diverticulosis of the colon.
• Physical inactivity.
• Improper diet: abuse of high-fat, high-calorie foods, sweets.
• Prolonged fasting, diets . A break in eating for more than 8 hours, as well as a long diet that does not contain animal fats, leads to stagnation in the gallbladder.
• Taking certain medications, such as steroid hormones and oral contraceptives.
• Changes in hormonal balance during pregnancy.
• Smoking and alcohol abuse .

Symptoms of gallstone disease

The manifestations of the disease are extremely diverse. Most often, the following forms of GSD are distinguished:

• latent,
• chronic dyspeptic,
• chronic pain,
• chronic relapsing,
• other forms.

In a certain sense, these forms can be considered as stages in the development of cholelithiasis. In the same patient, after a period of latent course, dyspeptic disorders may appear, after a while – a moderately severe pain syndrome and, finally, typical attacks of hepatic colic. However, such a development of the disease is far from necessary. Often, its first manifestation may be an attack of acute cholecystitis and hepatic colic.

Dyspeptic form of cholelithiasis

It is characterized by complaints associated with a violation of the digestive process. There is a feeling of heaviness in the stomach, heartburn, flatulence, unstable stool. Usually these sensations occur periodically, but can be permanent. They usually occur after meals. Moreover, patients often associate their appearance with the use of certain foods: fatty, fried, spicy dishes. The appearance of complaints can also be associated with taking too large portions of food.

Painful chronic form of cholelithiasis

It proceeds without bouts of acute pain. The pains are aching in nature, localized under the pit of the stomach and in the right hypochondrium, aggravated after eating, especially fatty foods. Their irradiation to the region of the right scapula is characteristic. The long existence of stones in the gallbladder can last indefinitely, but, ultimately, leads to the occurrence of an inflammatory process in it.

Chronic calculous cholecystitis

One of the frequent manifestations of chronic calculous cholecystitis is constant heaviness and pain in the right hypochondrium, nausea, which is aggravated by fatty and spicy foods. Small stones can be manifested by hepatic colic: an attack of acute pain in the right side of the abdomen, sometimes in the epigastric region. An attack can be triggered by the intake of fatty spicy foods or alcohol, as well as shaking while driving or stress. Vomiting and nausea are frequent companions of pain. Characterized by irradiation of pain in the right shoulder blade, right shoulder or right arm. The cause of a painful attack may be wedging a stone into the neck of the gallbladder. This leads to severe spasm. The gallbladder itself at this time is significantly reduced, trying to push out the bile, but a stuck stone prevents it from leaving. The duration of the pain attack is different – from several minutes to many hours and even days. If the obstruction has been removed and the stone has ceased to block the exit from the gallbladder, the symptoms quickly subside. Vomiting stops, temperature normalizes; general well-being improves. For some time, weakness and a feeling of weakness persist, and dyspeptic phenomena are occasionally noted. The patient’s condition may remain quite satisfactory until the next attack, which may develop in a few days, weeks, months or years.

Consequences of chronic cholecystitis

People who suffer from chronic cholecystitis for a long time end up risking their health and even their lives. The inflammatory process from the gallbladder spreads to neighboring organs, primarily the pancreas and liver. Almost all such patients have a chronic form of pancreatitis and changes in the liver. At the same time, irreversible changes occur in the gallbladder, which leads to three options for the development of the disease.

1. 1. The process of gallstone formation does not stop. The addition of infection and inflammation creates favorable conditions for the growth and formation of new stones. The bubble is filled with stones and ceases to be a reservoir for the accumulation of bile. It cannot perform its main functions in the digestive process. Food is poorly digested.
2. 2. Frequent inflammation of the gallbladder due to attacks of hepatic colic leads to a change in the wall of the gallbladder: it becomes overgrown with adhesions, and the muscles are replaced by dense scar tissue. The bladder cavity sharply decreases in size, a “scar-wrinkled bladder” is formed, which also does not participate in the digestion process.
3. 3. When the cystic duct is blocked by a stone, the bladder becomes large and overdistended. Overflowing with bile, which does not find a way out, the bladder loses its ability to contract, and even after the stone leaves the duct, it remains stretched, while it is no longer able to push out the bile. Gradually, the contents become colorless – “white bile”. Hydrocele of the gallbladder develops. Sometimes it is asymptomatic (apparently, the patient simply forgets about the attack). However, if dropsy appeared after an attack of hepatic colic, the enlarged gallbladder remains painful for a long time. Such a gallbladder is also turned off from the digestion process. In addition, bile, which remains in the gallbladder and is not renewed, easily suppurates when an infection joins, gallbladder empyema develops.

It is necessary to carry out a differential diagnosis of biliary (hepatic) colic from an attack of acute calculous cholecystitis. This is inflammation of the gallbladder, provoked by the presence of stones in it, which is manifested not only by severe pain, but also by the presence of fever, signs of intoxication, sometimes positive peritoneal symptoms and requires emergency inpatient treatment. The appearance of a fever, jaundice, and a decrease in blood pressure in a patient with cholelithiasis requires the exclusion of such possible complications as acute cholecystitis, pancreatitis, cholangitis, etc.

Basic methods for diagnosing gallbladder stones

Laboratory studies

1. With an exacerbation of gallstone disease, changes in the clinical blood test are observed: the number of leukocytes increases with the appearance of their young forms, the ESR rises, which indicates the presence of an inflammatory process. There may be changes in the biochemical parameters of the blood: an increase in the level of hepatic transaminases, amylase, lipase, total bilirubin. In most cases of asymptomatic stone carrying, the blood test may not be changed. Also, without changes in laboratory parameters, short attacks of biliary colic can pass.

Instrumental diagnostics

1. 1. The most accessible and effective method for screening diagnostics of all stages of cholelithiasis is abdominal ultrasound (ultrasound). Ultrasound of the liver and gallbladder allows you to see stones in the bladder cavity, determine their size, mobility, evaluate the size of the residual cavity of the gallbladder, identify signs of inflammation or deformation of its wall. Also, with ultrasound, the intra- and extrahepatic bile ducts are clearly visible, it is possible to assess their deformation, expansion and the presence of additional inclusions (calculi) in them.
2. 2. A more accurate diagnosis of the condition of the biliary tract is shown by magnetic resonance imaging – MR cholangiography.
   When performing MR – cholangiography, an image of the gallbladder, cystic duct, segmental, lobar ducts, common hepatic duct, choledochus and main pancreatic duct is obtained. You can evaluate their deformation, identify the expansion or narrowing of their lumen in certain areas. It becomes possible to accurately visualize stones not only in the gallbladder, but also in the lumen of the bile ducts. Additional examination methods for cholelithiasis include computed tomography (CT) and videoduodenoscopy.
3. 3. Computed tomography (CT) of the abdominal cavity is performed in case of suspected pathology of neighboring organs (liver, pancreas), in case of suspected oncological pathology in the biliary system.
4. 4. Video gastroduodenoscopy is an endoscopic examination that resembles video gastroscopy, but is performed using a special endoscope with lateral optics, which allows you to clearly see the area of ​​\u200b\u200bthe major duodenal papilla or “papilla of Vater” (the place where the bile ducts enter the duodenum).

Treatment of cholelithiasis and chronic calculous cholecystitis

Conservative treatment of gallstones

In the arsenal of doctors there are preparations of ursodeoxycholic acid, which changes the chemical composition of bile. These are drugs henofalk and ursofalk, they are prescribed for the purpose of drug lithosis (dissolution of stones). Treatment should be carried out against the background of strict adherence to diet and diet, as well as anti-inflammatory therapy. The duration of treatment is up to 2.5-3 years and does not always achieve the desired result. It should be remembered that true “stones”, consisting mainly of calcium, do not dissolve. Therefore, drug treatment can be used only in the initial stages of the disease, when the sediment in the bile is mainly represented by cholesterol stones.

Gallbladder removal surgery with stones

Cholecystectomy – removal of the gallbladder – the main method of surgical treatment. The operation is performed either in an open way through an incision in the abdominal wall, or laparoscopically – endovideosurgical cholecystectomy. The purpose of the operation: removal of the gallbladder with stones. The difference lies only in what instruments the surgeon works with and in what way the gallbladder with stones is removed.

In an open surgical operation, the incision through which the bladder is removed can be made from the xiphoid process to the navel, or the second access is in the right hypochondrium. The laparoscopic method is less traumatic – special instruments and optics are inserted through 4 small incisions on the skin. With the help of these tools, the gallbladder is removed. After such an operation, the scars are hardly noticeable. The length of stay in a hospital bed is 2-3 days. A week later, the patient is well.

Patient essential

In the modern world, cholelithiasis is a well-studied pathology, and laparoscopic surgery is the “gold standard of treatment”. Unfortunately, many people do not pay attention to the initial manifestations of the disease, do not undergo clinical examination or preventive examination to detect stones in the gallbladder. As a result, the disease is detected at late stages, when drug treatment is not only ineffective, but also contraindicated, and the success of a minimally invasive surgical operation also becomes doubtful.

In the presence of the complaints described above, as well as the listed risk factors, it is necessary to contact a surgeon or a gastroenterologist for recommendations on examination and selection of optimal treatment or preventive measures.

Our Clinic performs a full range of diagnostics, surgical and endoscopic treatment of cholelithiasis and its complications. Surgical operations in most cases are performed minimally invasively using laparoscopic and endoscopic technologies.

Choledocholithiasis: stones in the bile ducts operation

Choledocholithiasis is one of the manifestations of cholelithiasis, in which stones are found not in the gallbladder, but in the bile ducts. Most often – in the common bile duct.

Moreover, they either get there from the gallbladder, or are formed directly in the choledochus. As a rule, the treatment of such a disease is surgical. Note that the disease is quite serious, especially in cases where severe complications develop in the form of blocking the duct, then there is a threat to the life of the patient.

How do stones appear in the bile duct?

They usually form in the gallbladder and travel with bile through the cystic duct. At the same time, the general appearance of stones located in the bladder and in the ducts, their microstructure and chemical composition are identical. Evidence of the vesicular origin of calculi is the presence of faces on their surface, which are formed due to the contact of several stones in the gallbladder. The probability of moving stones in the choledoch is the greater, the wider the diameter of the cystic duct. In some cases, stone formation can occur directly in the lumen of the choledochus itself. This occurs when there is difficulty in the outflow of bile through the ducts.

The reasons for the formation of stones in the biliary tract can be:

• Stenosis of the terminal (final) part of the choledochus.
• Penetration from the duodenum of some helminths (roundworm, cat fluke).
• Production of bile with especially high lithogenic properties in some geographical regions (the so-called Far Eastern choledocholithiasis). The mechanism for the formation of such bile is still unknown. In these cases, choledocholithiasis is considered primary.
• Sometimes bile duct stones are detected some time later (several months, sometimes several years) after a previous cholecystectomy. These can be either stones that were not detected before the operation and during its execution (“residual” or “forgotten”), or newly formed (“recurrent” choledocholithiasis) that formed in the bile ducts after surgery due to metabolic disorders, stagnation of bile or the presence of infection.

Diagnosis of choledocholithiasis (stones in the bile ducts)

Diagnosis of choledocholithiasis cannot be based only on the clinic. Cystic stones in the common bile duct are not always clinically detected, and may exist asymptomatically for a long time. Only the appearance of an attack of hepatic colic followed by jaundice suggests a possible problem in the biliary tract. The nature of hepatic colic in choledocholithiasis is no different from that coming from the gallbladder. Although sometimes the pain can be localized somewhat higher and more medially than with cholecystolithiasis, in the epigastric region. Even more rarely, unbearable pain is observed with a sudden blockage of the duodenal papilla by a stone (the so-called “papillary ileus”).

In the presence of small (less than 5-7 mm) calculi in the gallbladder, any patient with cholelithiasis should suspect the presence of stones in the common bile duct, since such sizes allow them to freely migrate through the cystic duct. You should be especially wary of bilirubinemia (even a slight increase in serum bilirubin). Usually, the level of alkaline phosphatase increases at the same time, probably an increase in the level of aminotransferases. However, after the obstruction (blockage) is removed, the level of aminotransferases usually returns to normal quickly. While the level of bilirubin often remains elevated for 2 weeks, elevated levels of alkaline phosphatase persist even longer.

Laboratory diagnostics.

Asymptomatic choledocholithiasis may not be accompanied by changes in laboratory tests. With the development of inflammation in the blood, the level of leukocytes, ESR increases. In case of violation of the outflow of bile, an increase in the concentration of bilirubin (due to the direct fraction), an increase in the level of aminotransferases (transaminases) and alkaline phosphatase in the biochemical blood test are observed, and the content of bile pigments in the urine increases. There may be no stercobilin in the feces. A very formidable laboratory symptom is an increase in blood amylase, as this indicates a lesion of the pancreas.

Instrumental diagnostics.

Ultrasound examination of the abdominal organs (ultrasound) is the most accessible method for examining the biliary tract, in fact, a screening method. Its sensitivity to detect expansion of the common bile duct is up to 90%. However, it is not always possible for an ultrasound specialist to examine the terminal section of the common bile duct (the area where the common bile and pancreatic ducts merge and flow into the duodenum), i.e., a very important section for making the correct diagnosis. Inspection may interfere with gas or liquid (even in small quantities) in the intestine.

Therefore, in many cases it is necessary to resort to additional methods:

• Endoscopic ultrasound (endosonography). Examination is carried out with a special endosonographic probe through the lumen of the stomach and duodenum. With such an examination, the effectiveness of correct diagnosis increases to 85-100%.

• MPT cholangiography. The accuracy of this research method is up to 97%. When performing MRI cholangiography, an image of the gallbladder and cystic duct, segmental, lobar bile ducts, common hepatic duct, choledochus and pancreatic duct is obtained. It becomes possible to accurately visualize stones in the lumen of the ducts, their narrowing or expansion. The great advantages of MRI cholangiography include its non-invasiveness and the absence of the need for the use of contrast agents.

The following two diagnostic methods are invasive, so they can only be used when the patient is in the hospital. We are talking about endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTCG).

• ERCP is a standard method for diagnosing choledocholithiasis, in the hands of an experienced endoscopist it is effective in 90 – 95% of cases. However, this method is associated with the possible development of serious complications: hyperamylasemia, cholangitis, pancreatitis, retroperitoneal perforation of the duodenum, bleeding. Therefore, its use must be justified.
• Percutaneous transhepatic cholangiography is used in patients with obstructive jaundice when retrograde cholangiopancreatography cannot be performed. At the same time, under the control of ultrasound or an X-ray unit, an expanded duct of the right or left lobe of the liver is punctured through the skin. After evacuation of bile, a contrast agent is injected into the lumen of the bile duct and a series of images is taken. This allows you to get a clear image of the biliary tract, determine the cause of obstructive jaundice and the level of obstruction.

Additional examination methods include computed tomography and videoduodenoscopy.

• Computed tomography (CT) of the abdominal cavity is used for suspected compression of the bile ducts from the outside, or the presence of a neoplasm in their lumen.
• Video duodenoscopy is an endoscopic examination using a special endoscope with side optics, which allows a good examination of the area of ​​​​the major duodenal papilla or “papilla of Vater” (the place where the bile ducts enter the duodenum). This is a very important study, because sometimes the cause of choledocholithiasis is the pathology of the papilla of Vater (inflammation, cicatricial stricture, tumor, or wedged calculus).

Main manifestations of choledocholithiasis

• Attack of biliary colic.
  Stones in hepaticocholedochus injure its wall. Damage to the mucosa occurs especially easily in the narrowest part – in the region of the large duodenal papilla. Therefore, the main and most striking symptom of hepatic colic is pain. The sensation of pain in choledocholithiasis is practically no different from colic in cholecystolithiasis. Its irradiation is characteristic in the back or lower back. The pain can acquire a girdle character if the calculus overlaps in the region of the Vater papilla located in the duodenum 12. In this case, there is a violation of the outflow of both bile and pancreatic juice, as a result, the pancreas suffers.

• Mechanical (subhepatic) jaundice.
  When the stones obstruct the duct, the pressure in the biliary tract increases, the latter expand, but blockage by the stone prevents the flow of bile into the intestinal tube, the so-called acholic stool (lightening of the feces) and dark urine (beer color) appear.
  Thus, obstructive jaundice develops. Difficulty in the outflow of bile through the biliary tract leads to the fact that bilirubin appears in the blood – a bile pigment that saturates the tissues of a sick person. Human skin, sclera, mucous membranes acquire a yellow color.

• However, complete blockage and persistent jaundice with choledocholithiasis are not so common. At the same time, any obstruction to the outflow of bile creates favorable conditions for the development of infection and inflammation in the ducts. There is cholangitis , which easily develops against the background of damage to the mucous membrane. Due to repeated trauma and inflammation, narrowing of the lumen of the duct can form along its length and in the region of the major duodenal papilla – stenosing cholangitis and papillitis. The spread of the inflammatory process upward, towards the liver, can lead to a serious complication: cholangiogenic liver abscess. It should also be noted that the diameter of the common bile duct, of course, reflects the state of hypertension in it, but this is far from always the case – with narrow ducts, choledocholithiasis can also form. The inflammatory process is manifested by an increase in body temperature, chills, skin itching. In typical cases, cholangitis is accompanied by septic fever. Less typical for choledocholithiasis are small temperature peaks that accompany attacks of pain.

• With latent choledocholithiasis , a complaint of dull pain under the right costal arch is characteristic.

• With dyspeptic form of choledocholithiasis , the patient complains of uncharacteristic pressing pain under the right costal arch or in the epigastric region, dyspepsia, nausea, belching, gas and intolerance to fatty foods.

Learn more about the complications of choledocholithiasis

1. 1. Cholangitis. As mentioned earlier, in the presence of stones in the bile ducts, the infection has the conditions for its development, this leads to inflammation – cholangitis. When this complication occurs, a high temperature appears with chills and heavy sweats, severe pain in the right hypochondrium, nausea, and vomiting. marked general weakness. The danger of this complication is due to the fact that against the background of a developing infection, liver function is impaired. In addition, if treatment is not carried out in a timely manner, there is a risk of the formation of a liver abscess, as mentioned above, and in the future – the development of general sepsis and liver failure.

2. 2. Jaundice . Always stagnant. The blockage is usually incomplete and the intensity of the increase in bilirubin fluctuates. Suspicious in relation to choledocholithiasis should be not only any jaundice against the background of hepatic colic, but also fleeting subicteria, especially if it is often repeated. However, even severe choledocholithiasis is not always manifested by jaundice. Kehr also noted that sometimes when stones were piled up, bile, “like a mountain stream, freely overflows through stones.” More than 1/3 of patients with choledocholithiasis do not have jaundice. Significantly less often there is a manifestation of jaundice without accompanying biliary colic.

3. 3. Acute pancreatitis. The common bile duct and the pancreatic duct in humans in 70% of cases merge into one channel and flow together into the duodenum. When this common channel is blocked by a stone (usually at the exit to the duodenum), both bile and pancreatic enzymes lose their ability to be released into the intestine. There is an increase in pressure in the bile and pancreatic ducts, which leads to a severe complication – acute pancreatitis. Acute inflammation of the pancreas is a very serious disease, often fatal. Immediate surgical treatment is required in order to remove this obstruction, as well as other therapeutic measures.

Stones in the bile ducts – surgery

Treatment of choledocholithiasis can only be surgical. However, this does not mean that a major operation with a large incision in the abdomen is mandatory.
Most often, with choledocholithiasis, calculi of the bile ducts are removed endoscopically.

In the hospital, the patient undergoes ERCP to clarify the presence of a stone, its localization and other parameters. If the diagnosis of choledocholithiasis is confirmed, this study turns from diagnostic to therapeutic. Dissection of the narrowed zone of the Vater’s papilla (papillosphincterotomy), crushing of stones (lithotripsy) or their removal (extraction) is performed.