What are gallstones. How do gallstones form. What are the risk factors for developing gallstones. What symptoms do gallstones cause. How are gallstones diagnosed and treated. What complications can arise from gallstones. How can gallstones be prevented.

Understanding Gallstones: Formation and Types

Gallstones are solid, pebble-like deposits that form in the gallbladder. They develop when the solubility of bilirubin or cholesterol in bile is exceeded, leading to precipitation and crystal formation. There are two main types of gallstones:

• Cholesterol stones: These account for about 80% of gallstones and are primarily composed of hardened cholesterol.
• Pigment stones: These are darker in color and consist mainly of bilirubin, a breakdown product of hemoglobin.

Gallstone formation is a complex process influenced by various factors. In the case of cholesterol stones, an imbalance in the mechanisms that maintain cholesterol in solution within bile plays a crucial role. The risk of cholesterol precipitation is directly related to its concentration and inversely related to the concentrations of bile salts and lecithin.

The Role of Bile in Gallstone Formation

Bile, produced by the liver and stored in the gallbladder, plays a vital role in digestion and also in the formation of gallstones. When the composition of bile becomes imbalanced, it can lead to the precipitation of cholesterol or bilirubin, resulting in stone formation.

Can bile composition be altered to prevent gallstone formation? While it’s not always possible to prevent gallstones, certain dietary and lifestyle changes may help maintain a healthier bile composition. These include maintaining a healthy weight, eating a balanced diet rich in fiber, and staying hydrated.

Epidemiology and Risk Factors for Gallstones

Gallstones are a common health issue, particularly in Western countries. In the United Kingdom, approximately 8% of the population over 40 years old have gallstones, with the prevalence rising to over 20% in those aged 60 and above. Interestingly, about 90% of these stones remain asymptomatic.

The incidence of gallstones varies widely across different populations and is influenced by several factors:

• Age: The risk increases with age, particularly after 40.
• Gender: Women are more likely to develop gallstones than men.
• Ethnicity: Some ethnic groups, such as Native Americans, have a higher risk.
• Diet: High-fat diets can increase the risk of cholesterol stones.
• Obesity: Excess body weight is a significant risk factor.
• Rapid weight loss: Paradoxically, losing weight too quickly can also increase risk.
• Genetics: Family history plays a role in gallstone formation.

Are there specific populations at higher risk for gallstones? Indeed, certain groups face an elevated risk. For instance, the native Indian populations of Chile and Peru have an extremely high lifetime risk of gallstones, approaching 100% in women. This underscores the significant role that genetic factors play in gallstone formation.

Lifestyle and Medical Factors Influencing Gallstone Risk

Several lifestyle and medical conditions can increase the likelihood of developing gallstones:

1. Sedentary lifestyle
2. Pregnancy
3. Use of oral contraceptives or hormone replacement therapy
4. Diabetes
5. Liver disease
6. Certain medications (e.g., cholesterol-lowering drugs)

Does diet play a significant role in gallstone formation? Absolutely. A diet high in refined carbohydrates and saturated fats can increase the risk of gallstones. Conversely, a diet rich in fiber, fruits, vegetables, and healthy fats may help reduce the risk.

Recognizing Gallstone Symptoms: From Mild to Severe

While many gallstones remain asymptomatic, when they do cause symptoms, they can range from mild discomfort to severe pain. The most common symptom associated with gallstones is biliary colic, which typically presents as:

• Sudden, intense pain in the upper right abdomen
• Pain that may radiate to the back or right shoulder
• Episodes lasting from a few minutes to several hours
• Pain that often occurs after meals, particularly fatty foods

However, gallstone symptoms can be quite varied and may include:

• Nausea and vomiting
• Indigestion or heartburn
• Intolerance to fatty foods
• Jaundice (yellowing of the skin and eyes)
• Fever and chills (if infection is present)

Can gallstones cause pain in locations other than the upper right abdomen? Yes, while the upper right quadrant is the most common site of gallstone pain, some individuals may experience pain in the epigastrium, lower chest, or even on the left side of the abdomen. This variability can sometimes make diagnosis challenging.

Silent Gallstones: When Stones Go Unnoticed

It’s important to note that many people with gallstones never experience symptoms. These “silent” gallstones are often discovered incidentally during imaging tests for other conditions. In most cases, asymptomatic gallstones do not require treatment unless they begin to cause problems.

Diagnosing Gallstones: Imaging and Laboratory Tests

When gallstones are suspected, several diagnostic tools can be employed to confirm their presence and assess their impact on the biliary system:

1. Ultrasound: This is typically the first-line imaging test for gallstones. It’s non-invasive, cost-effective, and highly accurate in detecting stones in the gallbladder.
2. CT scan: While less sensitive than ultrasound for gallstones, CT scans can provide detailed images of the entire abdominal area, helping to identify complications or alternative causes of symptoms.
3. MRCP (Magnetic Resonance Cholangiopancreatography): This specialized MRI technique provides detailed images of the bile ducts and can detect stones that may have migrated into the common bile duct.
4. ERCP (Endoscopic Retrograde Cholangiopancreatography): This procedure combines endoscopy with X-ray imaging and can be both diagnostic and therapeutic, allowing for the removal of stones from the bile duct.
5. Blood tests: While not diagnostic for gallstones themselves, blood tests can help assess liver function and detect signs of infection or inflammation.

What is the most reliable method for diagnosing gallstones? Ultrasound is generally considered the gold standard for diagnosing gallstones due to its high sensitivity and specificity, particularly for stones in the gallbladder. However, the choice of diagnostic test may depend on the specific clinical situation and suspected complications.

The Importance of Accurate Diagnosis

Accurate diagnosis is crucial not only for confirming the presence of gallstones but also for guiding treatment decisions. In some cases, symptoms similar to those caused by gallstones may be due to other conditions, such as peptic ulcer disease or functional gastrointestinal disorders. Therefore, a thorough diagnostic workup is essential to ensure appropriate management.

Treatment Approaches for Gallstones: From Watchful Waiting to Surgery

The treatment of gallstones depends on various factors, including the presence and severity of symptoms, the size and location of the stones, and the overall health of the patient. Treatment options include:

1. Watchful waiting: For asymptomatic gallstones, a “wait and see” approach is often recommended, as many people never develop symptoms.
2. Lifestyle modifications: Dietary changes and weight loss may help manage symptoms and reduce the risk of complications in some cases.
3. Medications: Certain medications, such as ursodeoxycholic acid, may be used to dissolve small cholesterol stones over time, although this approach is less common.
4. Laparoscopic cholecystectomy: This minimally invasive surgical procedure to remove the gallbladder is the most common and effective treatment for symptomatic gallstones.
5. Open cholecystectomy: In some cases, a traditional open surgery may be necessary, particularly if there are complications or anatomical variations.
6. ERCP with stone extraction: For stones in the common bile duct, this procedure can be used to remove the stones without surgery.

Is surgery always necessary for gallstones? No, surgery is not always required. For asymptomatic gallstones or those causing only mild, infrequent symptoms, conservative management may be appropriate. However, for recurrent or severe symptoms, or in cases where complications are present or likely to develop, surgery is often the recommended course of action.

The Role of Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy has become the gold standard for treating symptomatic gallstones. This minimally invasive procedure offers several advantages over traditional open surgery:

• Smaller incisions and less scarring
• Reduced post-operative pain
• Shorter hospital stay
• Quicker recovery and return to normal activities
• Lower risk of complications

Most patients who undergo laparoscopic cholecystectomy experience significant relief from their symptoms and can resume a normal diet without restrictions related to gallbladder function.

Complications of Gallstones: When Stones Cause Serious Problems

While many gallstones remain asymptomatic, they can sometimes lead to serious complications that require prompt medical attention. These complications include:

1. Cholecystitis: Inflammation of the gallbladder, often due to a stone blocking the cystic duct.
2. Choledocholithiasis: Stones that migrate from the gallbladder into the common bile duct, potentially causing obstruction.
3. Cholangitis: Infection of the bile ducts, which can be life-threatening if not treated promptly.
4. Pancreatitis: Inflammation of the pancreas, which can occur if a gallstone blocks the pancreatic duct.
5. Gallbladder cancer: Although rare, chronic inflammation due to gallstones may increase the risk of gallbladder cancer.

Can gallstones cause liver damage? While gallstones themselves don’t directly damage the liver, complications such as bile duct obstruction can lead to liver problems if left untreated. Prolonged obstruction can cause backup of bile into the liver, potentially leading to inflammation, infection, or even liver damage in severe cases.

Recognizing and Addressing Gallstone Emergencies

Some gallstone complications, such as acute cholecystitis or cholangitis, can be medical emergencies requiring immediate intervention. Symptoms that may indicate a gallstone emergency include:

• Severe, persistent abdominal pain
• High fever and chills
• Jaundice
• Persistent nausea and vomiting
• Signs of shock (rapid heartbeat, low blood pressure)

If these symptoms occur, immediate medical attention is crucial to prevent potentially life-threatening complications.

Preventing Gallstones: Lifestyle Choices and Risk Reduction

While not all gallstones can be prevented, certain lifestyle choices may help reduce the risk of their formation:

1. Maintain a healthy weight: Obesity is a significant risk factor for gallstones. Gradual, sustainable weight loss can help reduce risk.
2. Eat a balanced diet: A diet rich in fiber and healthy fats, and low in refined carbohydrates and saturated fats, may help prevent gallstones.
3. Stay hydrated: Drinking plenty of water may help maintain proper bile composition.
4. Exercise regularly: Physical activity can help maintain a healthy weight and may improve gallbladder function.
5. Avoid rapid weight loss: Losing weight too quickly can increase the risk of gallstones. Aim for gradual, steady weight loss if needed.
6. Consider preventive medications: In high-risk individuals, medications like ursodeoxycholic acid may be prescribed to prevent gallstone formation.

Do certain foods help prevent gallstones? While no specific food can guarantee prevention of gallstones, a diet rich in fiber (found in fruits, vegetables, and whole grains) and healthy fats (such as those in olive oil and fish) may help reduce the risk. Additionally, some studies suggest that moderate coffee consumption may have a protective effect against gallstones.

The Role of Regular Check-ups

Regular medical check-ups can play an important role in gallstone prevention and early detection. During these visits, healthcare providers can assess risk factors, provide personalized prevention strategies, and, if necessary, detect gallstones before they become symptomatic or cause complications.

For individuals with a family history of gallstones or other high-risk factors, more frequent monitoring may be recommended. This proactive approach can help catch potential issues early and guide appropriate interventions.

Living with Gallstones: Management and Quality of Life

For those diagnosed with gallstones, whether symptomatic or asymptomatic, understanding how to manage the condition and maintain a good quality of life is crucial. Here are some key considerations:

• Dietary modifications: While there’s no specific “gallstone diet,” avoiding fatty, greasy foods may help reduce symptoms in some people.
• Symptom management: Understanding triggers for gallstone pain and how to manage mild symptoms can help improve daily life.
• Regular follow-ups: Even for asymptomatic gallstones, regular check-ups with a healthcare provider are important to monitor for any changes or developing complications.
• Mental health: Dealing with chronic pain or the anxiety of potential gallstone attacks can be stressful. Addressing mental health concerns is an important part of overall management.
• Physical activity: Regular exercise can help maintain a healthy weight and may improve gallbladder function.

How does gallbladder removal affect digestion and lifestyle? After gallbladder removal (cholecystectomy), most people can return to a normal diet and lifestyle. The liver continues to produce bile, which flows directly into the small intestine. Some individuals may experience temporary changes in bowel habits, but serious long-term complications are rare.

Coping with Recurring Symptoms

For those who experience recurring gallstone symptoms but are not immediate candidates for surgery, several strategies can help manage discomfort:

1. Identifying and avoiding trigger foods
2. Eating smaller, more frequent meals
3. Using heat therapy for pain relief
4. Practicing stress-reduction techniques
5. Working with a healthcare provider to develop a personalized management plan

By adopting these strategies and working closely with healthcare providers, many individuals with gallstones can effectively manage their condition and maintain a good quality of life.

ABC of the upper gastrointestinal tract: Upper abdominal pain: Gall bladder

BMJ. 2001 Nov 17; 323(7322): 1170–1173.

ABC of the upper gastrointestinal tract

This article has been cited by other articles in PMC.

Gall stones are common but often do not give rise to symptoms. Pain arising from the gall bladder may be typical of biliary colic, but a wide variety of atypical presentations can make the diagnosis challenging. After a period of uncertainty in the 1980s, when operative techniques were challenged by drug treatment and lithotripsy, it is now widely accepted that symptomatic gallbladder stones should be treated by laparoscopic cholecystectomy. Clinical judgment and local expertise will greatly influence the management of bile duct stones, particularly if cholecystectomy is also required.

Asymptomatic gall stones are common and require no treatmentTypical symptoms include biliary colic—right upper quadrant pain, radiating to the back, and lasting less than 12 hoursSymptomatic gall stones are usually treated by laparoscopic cholecystectomy

Epidemiology of gall stones

In the United Kingdom about 8% of the population aged over 40 years have gall stones, which rises to over 20% in those aged over 60. Fortunately, 90% of these stones remain asymptomatic, but cholecystectomy is the most commonly performed abdominal procedure.

Risk factors for gall stones

Cholesterol stones

• Obesity

• High fat diet

• Oestrogens (female, pregnancy, oral contraception)

• Hereditary

• Loss of bile salts (Crohn’s disease, terminal ileal resection)

• Impaired gall bladder emptying (such as truncal vagotomy, type 1 diabetes, octreotide, parenteral nutrition, and starvation or rapid voluntary weight loss)

Pigment stones

• Haemolytic disease

• Biliary stasis

• Biliary infection

The incidence of gall stones varies widely, being greatly influenced by dietary intake, particularly of fat. For example, in Saudi Arabia gallstone disease was virtually unheard of 50 years ago, but, with increasing affluence and a Western type diet, gall stones are now as common there as in many Western countries. Genetic factors also contribute. The native Indian populations of Chile and Peru are highly susceptible, with a close to 100% lifetime risk of gall stones in their female population. Several risk factors have been identified, which relate to the two major stone types, cholesterol stones and pigment stones.

Pathogenesis

Gall stones form when the solubility of bilirubin or cholesterol is exceeded. Pigment stones arise in the gall bladder when there has been increased bilirubin production from breakdown of haemoglobin. Mixed stones contain both bilirubin and cholesterol and may be calcified. Precipitated bilirubin may form a nidus for subsequent cholesterol deposition.

Secondary pigment stones form in the bile duct as a consequence of obstruction or by accumulation around a small primary stone. These stones are associated with bacterial infection and arise by bacterial deconjugation of the bilirubin-glucuronide complex.

Cholesterol stones arise because of an imbalance in the mechanisms maintaining cholesterol in solution. Cholesterol is a hydrophobic molecule and is dispersed in micelles by the combined action of bile salts and lecithin. The risk of precipitation is directly related to cholesterol concentration and inversely to the concentrations of bile salts and lecithin, giving rise to a triangular coordinate. Increased cholesterol excretion is largely of dietary origin but may also result from changes in steroid metabolism associated with pregnancy, oral contraceptives, and obesity.

Bile salts are retrieved from the gut by the terminal ileum, and this enterohepatic circulation is essential for maintenance of the bile salt pool. The endogenous synthesis of bile salt is rate limited at a level much lower than its normal daily excretion by the liver. Many gastrointestinal diseases affect bile salt metabolism—in particular, Crohn’s disease and surgical resection of the terminal ileum predispose people to gall stones.

Impaired gallbladder emptying predisposes to gall stones by increasing the time that material stays in the gall bladder, allowing excessive crystal growth. In addition, the dilating and flushing effect of fresh hepatic bile is lost when the gall bladder contracts poorly.

Symptoms associated with gall stones

Biliary colic is usually felt as a severe gripping or gnawing pain in the right upper quadrant. It may radiate to the epigastrium, or around the lower ribs, or directly through to the back. It may be referred to the lower pole of the scapula or the right lower ribs posteriorly. However, many variations on this pattern have been described, including retrosternal pain and abdominal pain only in the epigastrium or on the left side. Such symptoms, in the presence of gallbladder stones, merit consideration of cholecystectomy.

There may be difficulty when symptoms are less clear. In a year about 25% of the adult population consults a general practitioner for dyspeptic symptoms. As nearly 8% of these individuals will have asymptomatic gall stones, many patients with dyspeptic symptoms are given the label “gallstone dyspepsia.” A pattern of symptoms supposedly associated with gall stones has been described, but several careful studies of patients before and after cholecystectomy have failed to show any clear association with either a good or poor outcome. Since asymptomatic gall stones and dyspepsia are so common in the general populations, they often coexist. Dyspeptic symptoms may be too readily attributed to the presence of gall stones, leading to inappropriate and ineffective surgery. Not surprisingly, therefore, symptoms may persist in up to 20% of patients after cholecystectomy.

Symptoms associated with gall stones

Biliary colic

• Right subcostal or epigastric pain radiating to back or lower pole of scapula lasting for 20 minutes to 6 hours

• Associated with vomiting brought on by (any) food

• May disturb sleep

Complications

Gallbladder stones may be complicated by acute cholecystitis, mucocele, or empyema. These are difficult to distinguish clinically; a patient may present with an episode of acute cholecystitis that fails to resolve and at operation is found to have an empyema or a mucocele. In addition to symptoms of biliary colic, such patients have pain that is constant and lasts for more than 12 hours; they also have tenderness over the gall bladder, which may be palpable, and may have a fever and leucocytosis.

Symptoms of dyspepsia

not associated with gall stones

Complications of bile duct stones include obstructive jaundice and acute pancreatitis.

Any patient with suspected complications of either gallbladder or bile duct stones should be referred for urgent specialist assessment and may well require immediate admission to hospital.

Diagnosis

Ultrasonography has replaced cholecystography as the diagnostic test for gall stones. About 95% of gallbladder stones will be detected by ultrasonography, which is cheap, quick, and harmless. If strong clinical suspicion of gall stones exist, and ultrasonography does not show stones, the test should be repeated. Other diagnostic tests are less sensitive and are rarely indicated.

Management

The management of gall stones depends on their position, either in the gall bladder or bile duct.

Gallbladder stones

The management of gallbladder stones is now relatively straightforward. Asymptomatic gallstones require no intervention as the risks of any procedure outweigh the potential benefits.

Options for treatment of symptomatic gallbladder disease

• Laparoscopic cholecystectomy—Safe in specialist hands, rapid recovery,permanently effective, current gold standard

• Open cholecystectomy—Traditional, painful, prolonged recovery, scar

Alternative therapies

• Extracorporeal shock wave lithotripsy—Complex

• Bile salt dissolution—Expensive

• Percutaneous cholecyslithotomy—Leaves abnormal gall bladder in situ,high recurrence rate, suitable only for a few selected patients

In the 1980s dissatisfaction with the outcome of open cholecystectomy led to several alternative therapies such as extracorporeal shock wave lithotripsy and bile salt dissolution therapy. These treatments were restricted in their applicability and have been almost completely superseded by laparoscopic cholecystectomy. This procedure offers a more rapid recovery and return to work, much less abdominal scarring, and at least as good long term relief of symptoms as open cholecystectomy. In specialist hands almost all uncomplicated gallbladder stones can be dealt with laparoscopically, with minimal risk of injury to the bile duct.

Complicated gallbladder stones—If complications arise (such as acute cholecystitis, mucocele, or empyema) cholecystectomy is performed. This will usually be by the laparoscopic approach, but up to 10% of operations have to be converted to laparotomy. In some elderly patients with acute presentation, percutaneous cholecystostomy is performed under ultrasound control to relieve the infection and avoid the morbidity of an emergency operation. Subsequently, the stones may be extracted percutaneously, leaving the gall bladder in place, or, if appropriate, cholecystectomy is performed.

Stones in the bile duct

Stones may migrate from the gall bladder into the bile duct. Cholangiography is performed before, during, or immediately after cholecystectomy to demonstrate the presence or absence of bile duct stones in patients with known risk factors. A cholangiogram may be obtained endoscopically, at operation, or by means of magnetic resonance imaging. Uncomplicated bile duct stones should be removed when they are detected, because of the high risk of complications such as acute pancreatitis, obstructive jaundice, or cholangitis if they are left in situ.

The management of asymptomatic duct stones is controversial. The traditional approach of open cholecystectomy with exploration of the common bile duct offers simplicity and widespread applicability and avoids exposing the patient to the risk of procedure related pancreatitis. Alternatives are laparoscopic cholecystectomy with endoscopic sphincterotomy and stone extraction either before or after cholecystectomy, or else laparoscopic exploration of the common bile duct. Currently practice varies according to the expertise available locally.

Acalculous biliary pain

The symptoms of biliary colic are characteristic but may occur in the absence of gall stones. In such cases a specialist must decide whether an operation to remove the gall bladder is appropriate, in the belief that symptoms are due to microscopic crystals (microlithiasis) or to a structural abnormality of the cystic duct.

Risk factors suggesting presence of bile duct stones at cholecystectomy for symptomatic gallbladder stones

• Common bile duct dilated (>6 mm on ultrasound)

• Recent abnormal levels of liver enzymes or bilirubin

• History of acute pancreatitis

• History of obstructive jaundice

Occasionally, biliary colic seems to be associated with a high pressure sphincter of Oddi, and symptoms may resolve after endoscopic sphincterotomy. Alternative explanations for so called acalculous biliary pain include irritable bowel syndrome with upper gastrointestinal manifestations (see previous article). Chronic pancreatitis must also be carefully excluded. Any decision to carry out a cholecystectomy for this condition should be made by a hepatobiliary specialist.

Gallbladder cancer

Gallbladder cancer is rare and usually asymptomatic until at an advanced stage. Usually it is associated with gall stones and may be discovered incidentally at operation. Suspicious features in a patient with biliary symptoms include weight loss, anaemia, persistent vomiting, and a palpable mass in the right upper quadrant. Such patients require urgent investigation. The prognosis is good if the disease is diagnosed at an early stage, but complete resection is often not possible because of the advanced stage at presentation.

​

Mixed gall stone with bilirubin nucleus and attached clear cholesterol crystals

Triangular coordinates relating solubility of cholesterol with concentrations of cholesterol, bile salts, and lecithin

Enterohepatic circulation of bile salts. Each molecule circulates at least once for each meal

Top: Ultrasound image of gall bladder with dark area (a) representing gall bladder and multiple white echoes (b) representing stones. Bottom: The gall bladder after cholecystectomy with multiple small stones

Percutaneous cholecystostomy for acute cholecystitis. Percutaneous drainage relieves the acute phase, allowing subsequent stone extraction via the drain track or cholecystectomy when inflammation has resolved

Cholangiography for duct stones. Top left: Endoscopic retrograde cholangiogram showing two stones in the bile duct (arrows). Top right: Operative cholangiogram (no stones). Bottom: Magnetic resonance cholangiogram obtained by 3-D reconstruction from a single breath hold acquisition

Acknowledgments

The diagram of triangular coordinates relating cholesterol solubility with bile salts and lecithin is adapted from Admirand WH, Small DM. J Clin Invest 1968;47:1043-52. The magnetic resonance cholangiogram was kindly provided by Dr C N Hacking.

Footnotes

C D Johnson is reader in surgery at the University Surgical Unit (816), Southampton General Hospital, Southampton.

The ABC of upper gastrointestinal tract is edited by Robert Logan, senior lecturer in the division of gastroenterology, University Hospital, Nottingham; Adam Harris, consultant physician and gastroenterologist, Kent and Sussex Hospital, Tunbridge Wells; J J Misiewicz, honorary consultant physician and joint director of the department of gastroenterology and nutrition, Central Middlesex Hospital, London; and J H Baron, honorary professorial lecturer at Mount Sinai School of Medicine, New York, USA, and former consultant gastroenterologist, St Mary’s Hospital, London.

Gallstone – an overview | ScienceDirect Topics

Cholesterol and Mixed Stones

The requisite step in the formation of cholesterol and mixed stones is cholesterol supersaturation of bile within the gallbladder. Bile solubility, as well as bile supersaturation, is based on the relative molar concentrations of cholesterol, bile acids, phosphatidylcholine (lecithin), and water. Because free cholesterol is water insoluble, it must be incorporated into a lecithin–bile salt micelle (Fig. 171.2). Using triangular coordinates, it is possible to demonstrate the solubility of cholesterol in bile (Fig. 171.3).

As illustrated in the figures, either an increase in cholesterol secretion or a decrease in bile acid or lecithin secretion will lead the bile to become supersaturated. Once the bile is supersaturated, stone formation is initiated by such factors as biliary stasis, infection, and increased mucin secretion by the gallbladder epithelium. Once the stone begins to form, its radius increases at an average rate of 2.6 mm/year, eventually reaching a size of a few millimeters to more than a centimeter. Symptoms typically occur an average of 8 years after formation begins. Cholelithiasis is present in 95% of patients with cholecystitis.⁸

Risk Factors for Cholesterol and Mixed Stones

The major risk factors for the development of cholesterol and mixed gallstones include the following^2–4:

•

Diet

•

Gender

•

Race

•

Obesity

•

High caloric intake

•

Estrogens

•

Gastrointestinal diseases (especially Crohn’s disease and cystic fibrosis)

•

Drugs

•

Age

The role of a low-fiber, high-fat diet in the development of gallstones, as well as other dietary factors, is discussed later. The other factors are briefly discussed here.

Gender

The frequency of gallstones is two to four times greater in women than in men. Women are thought to be predisposed to gallstones because of either increased cholesterol synthesis or suppression of bile acids by estrogens. Pregnancy, the use of oral contraceptives or other causes of elevated estrogen levels, and tamoxifen use greatly increase the incidence of gallstones.

Genetic and Ethnic

The prevalence of gallstones appears to have some genetic aspects. Gallstones are most common in Native American women over age 30. Nearly 70% of this group have gallstones. In contrast, only 10% of black women over 30 have gallstones. The difference in the prevalence rate between ethnic and genetic groups reflects the extent of cholesterol saturation of the bile. The degree to which dietary factors affect this value probably outweighs genetic factors.⁹

Obesity

Obese subjects are at risk of developing gallstones by being overweight and when initially losing weight.¹⁰ Obesity causes increased activity of 3-hydroxy-3-methyl-glutaryl-CoA (HMG-CoA) reductase, with increased secretion of cholesterol in the bile as a result of increased cholesterol synthesis. Therefore obesity is associated with a significantly increased incidence of gallstones due to biliary cholesterol saturation.

It is important to note that during active weight reduction, changes in body fat and diet can promote gallstone problems. During the first stages of weight loss, biliary cholesterol saturation initially increases.⁴ The secretion of all biliary lipids is reduced during weight loss, but the secretion of bile acids decreases more than that of cholesterol. Once the weight is stabilized, bile acid output returns to normal levels, whereas the cholesterol output remains low. The net effect is a significant reduction in cholesterol saturation. In prescribing diet therapies for obese patients with a high risk of gallstones, it should be recognized that prolonged dietary fat reduction can also promote biliary stasis,¹ thus contributing to cholesterol saturation. Studies show that at least 10 g of fat per day is necessary to assure proper gallbladder emptying.¹¹

Gastrointestinal Tract Diseases

Malabsorption of bile acids from the terminal ileum disturbs the enterohepatic circulation, thereby reducing the bile acid pool and the rate of secretion of bile. Diseases associated with this phenomenon include Crohn’s disease and cystic fibrosis.

Drugs

Tamoxifen treatment in postmenopausal patients with breast cancer greatly increases gallstones. One retrospective cohort study of 703 women demonstrated that after 5 years, the incidence of stone formation in the tamoxifen-treated patients was 37.4%, whereas it was 2% in patients who did not receive tamoxifen.¹² Most gallstones became apparent after 3 years.

In addition to oral contraceptives and other estrogens, other drugs that increase the risk of gallstones include the cephalosporin ceftriaxone, octreotide, HMG-CoA reductase inhibitors,¹ and possibly other lipid-lowering drugs.

Age

Gallstones have been reported from fetal age to extreme old age, but the average patient is 40 to 50 years old. A decline in the activity of cholesterol 7-α-hydroxylase with age¹ leads to an increase in biliary cholesterol hypersecretion¹³ and thus cholesterol saturation, with an accelerated formation of gallstones.

Hypothyroidism

Patients with hypothyroidism are more prone to have high serum cholesterol levels. The mechanisms of thyroid hormones on cholesterol are multifactorial, including influencing the synthesis, absorption, and usage of cholesterol. Disturbances in lipid metabolism that occur during hypothyroidism, particularly in the cholesterol pathway, change the rate of bile excretion and lead to the formation of gallstones. In regression multivariate analysis, it has been concluded that the level of serum thyroid-stimulating hormone (TSH) was an independent factor that could be considered a risk factor for the formation of common bile duct stones (odds ratio [OR] = 3.07; 95% confidence interval [CI], 1.51–6.3).¹⁴

Environmental Pollutants

Metal contamination of both natural and anthropogenic origin has an adverse effect on human health. A study explored the effects of metal contamination on gallstone formation by comparing two environmentally contrasting populations in the Huelva Province of Southwest Spain.¹⁵ The study population resided in an area with high metal abundance derived from the naturally metal-enriched bedrock and historical mining activities in the region of the Iberian Pyrite Belt, whereas the control population resided in the National Park of Sierra de Aracena and Picos de Aroche. The patients from the study group had a higher risk of metal exposure through contaminated soil, particle matter in the air, and consumption of local water and food products. Results demonstrated that metal exposure was related to a higher tendency of forming black-pigment gallstones in the study group compared with the control group, and the gallstones from the study group contained more abundant metal components, such as copper, iron, nickel, and zinc. In addition, a study in India identified a positive correlation between nickel, cadmium, and chromium in water and a high prevalence of gallbladder disease in adjacent villages in Vaishali District, Bihar.¹⁶

Organochlorine pesticides (OCPs) are persistent organic pollutants (POPs) historically used in the agricultural control of pests. A case-control study from China showed that high levels of p,p′-DDE and p,p′-DDT residues were risk factors for gallstone formation.¹⁷ Because of their lipophilic property, OCPs can accumulate in adipose tissue and other organs. β-HCH and p′,p′-DDE levels in adipose tissues were found to be higher in patients with gallstones and strongly related to gallstone disease.¹⁸

Spilled gall stones during laparoscopic cholecystectomy: a review of the literature

Innovation creates opportunities and technical advances that change clinical practice. With the popularity and quality of diagnostic ultrasound and the therapeutic option of laparoscopic cholecystectomy, more gall stones are now detected and consequently operated upon. With better patient satisfaction and a shorter hospital stay, laparoscopic cholecystectomy has become the method of choice. However, this change in practice from open surgery has led to different problems such as biliary tract injuries and intraoperative spillage of stones. The first complication, though serious, can be minimised with experience, supervision, and good training, whereas the latter complication of spilled gall stones is often ignored. Gall stone spillage during laparoscopic cholecystectomy is common. This problem occurs less frequently in open surgery and the spilt stones are easy to retrieve.¹ Fortunately, clinically significant complications resulting from stones left in the peritoneum are extremely uncommon and because of this there has not been much discussion of the problem.

INCIDENCE

Perforation of the gall bladder occurs fairly frequently during laparoscopic cholecystectomy and is reported in the range of 10%–40% in various series (table 1).^2–7 The incidence of gall stone spillage is less frequent and the true incidence of unretrieved stones is difficult to determine. Some series quote a range 6%–30%.^8–10 Spillage of stones can occur during dissection of the gall bladder off the liver bed, tearing with grasping forceps, or during extraction of the gall bladder through one of the port sites. The incidence is more common when operating on an acutely inflamed gall bladder²; it is also more common in men, the elderly, obese patients, and in the presence of adhesions.⁵ Stones spilled may remain in the peritoneal cavity adjacent to the liver or may migrate to various distant sites. These stones can cause a range of complications and are discussed in this review article. In the majority of cases, these stones usually cause no bother and remain benign. Complications that result from these stones are said to occur in 0.08%–0.3% of patients.^2,11

Table 1

Complications of laparoscopic cholecystectomy reported in various series (percentages in parentheses)

PRESENTATION

Isolated case reports in the surgical literature convey the varied modes of clinical presentations arising secondary to stone spillage (table 2).

Table 2

Modes of clinical presentations secondary to stone spillage

The combination of pneumoperitoneum and peritoneal irrigation disperses calculi within the peritoneal cavity. This probably accounts for unusual sites of these complications. The exact reason why only a fraction of patients develop complications after stone spillage is uncertain. Multiple pigment stones (whose aetiology is infection) and the presence of infected bile lead to an inflammatory reaction and abscess formation. The time interval after surgery for these to present varies from as short as one month to as long as 20 years,^1,33 with a peak incidence usually around four months. In most instances, the body’s immune mechanisms cope, leading to spontaneous resolution. However, infective complications are noticed more often in elderly patients because of poorer immunological reaction.³³ Often the patients presenting with an abscess can be afebrile and have a normal white cell count.

PREDISPOSING FACTORS FOR COMPLICATIONS

The fate of the intraperitoneal gall stone has provoked several exciting experimental studies. Cline et al implanted sterile gall stones in the peritoneal cavity of rats.³⁴ The results of the study suggested spillage of sterile stones should not cause increased morbidity during or after laparoscopic cholecystectomy. Zorluoglu et al implanted gall stones inside the peritoneal cavity of the rats in combination with either sterile bile or infected bile, and they came to the conclusion that the combination of multiple stones and infected bile increased the incidence of adhesions and intra-abdominal abscesses.³⁵ Another study conducted in rats by Gurleyik et al came to the conclusion that chemical composition of the stones has a significant influence on the fate of intra-abdominal gall stones, and infection may aggravate local reactions and complications.³⁶ Increased adhesions and abscess formation has been shown in other studies on rat.^37,38 Infective complications are more likely to occur with bilurubinate stones because these stones often contain viable bacteria.³⁹

INVESTIGATIONS

The diagnosis is often delayed due to the unusual site of the abscess formation coupled with the lack of awareness of stone spillage during previous cholecystectomy. Only a high index of clinical suspicion may lead to correct identification. Ultrasound, computed tomography, and magnetic resonance imaging (MRI) are valuable as diagnostic tools. Radiologists should consider spilled stones as a potential source of recurrent abscesses in any patient presenting months or years after laparoscopic cholecystectomy. The presence of calculi within the abscess can often be identified using ultrasonography, computed tomography, or MRI and is diagnostic of spilled stones complicated by abscess formation. However, a non-opaque calculus within an abscess may not be visualised by standard imaging techniques and could result in confusion with diagnosis of abscess due to other causes, such as unusual infections like actinomycosis or tumour.

Ultrasound may identify radiolucent biliary stones in the middle of the inflammatory mass by detecting the hyperechoic acoustic signals from these stones. Ultrasound is more sensitive in detecting stones in abscesses compared with MRI⁴⁰ because with MRI it is difficult to differentiate between stones and gas in an abscess. Ultrasound is also more convenient and cost effective.

REMOVAL OF SPILLED STONES

Primary (prevention is better than cure)

(A) During surgery

Every attempt should be made to avoid spillage during surgery. Careful dissection and identification of correct planes between the wall of the gall bladder and surrounding structures should be strictly adhered to. Aspiration of a gall bladder full of bile before dissection to ease the tension on the wall can facilitate dissection.

(B) During extraction

Use of retrieval bags to retrieve the gall bladder decreases the chances of spillage during extraction and avoids inadvertent spillage to or contamination within port site wounds.

Secondary (what to do after spillage?)

In case of spillage, efforts should be made to retrieve the lost stones and the peritoneal cavity should be irrigated with saline to dilute any infected bile. Attempts at repairing gall bladder perforations are often unsatisfactory. Use of retrieval bags or even a surgical glove with a purse string attached to the opening is recommended to collect any spilled stones and the gall bladder.²¹ Other techniques recommended are placement of extra ports, use of 30–45 degree telescopes, copious irrigation, and pressure ejection whereby the cannula is manoeuvred directly over these stones and the port opened rapidly to eject stones through it.

To convert to open or not?

Conversion to open surgery for removal of spilled stones recognised during laparoscopic cholecystectomy is a controversial question. Although spillage can lead to severe postoperative complications, the incidence and mortality after it are extremely low. On this basis, routine conversion to open technique to retrieve the stones is not indicated.

Tertiary (treatment of complications of spilled stones)

In the literature, various methods have been described to deal with the infective complications associated with spilled stones. Treatment of complications basically depends on the location of the problem.

Abdominal wall abscess from stones caught at the port site can be dealt with by local drainage and evacuation of the stones. Stones which are the foci of infection in these abscesses and sinuses should be completely removed for a cure.^20,21

Intra-abdominal abscesses can be dealt with percutaneously by minimally invasive technique⁴¹ and laparotomy where this technique fails.^4,33 The percutaneous procedure has the advantage of being less invasive, having a short hospital stay and minimal discomfort, and is ideally suited for old patients. Computed tomography guided drainage of the pus is first done with a pigtail catheter. A few weeks later the tract is dilated with a dilator system and a nephroscope is passed through it and stones are removed.⁴² Treatment is not complete until all the stones that are present in the abscess are removed. The size of the stone is an important determinant. Smaller stones usually less than 1 cm can often be removed through the nephroscope and using a basket. Larger ones need fragmentation by mechanical means or lithotripsy before attempting removal. Ultrasonic lithotripsy requires a rigid endoscope and keeps stone fragments to a minimum, thereby minimising the risk of breaking an infected stone into tiny fragments, which may serve as a nidus for further infection. In dealing with a deep seated abscess with a tortuous tract electrohydraulic lithotripsy in association with choledochoscopy is a good alternative.⁴³ A completion contrast study (abscessogram) is recommended to check for the intactness of the cavity and for any retained stones.

Gall stones found at distant sites, as described in some case reports (table 2), have been an incidental finding and can be found in a hernial sac, in urine, or in sputum. Gall stones causing vesical granulomas resulting in haematuria have been dealt with by cystoscopic excision of the granulomas.³¹

CONCLUSION

Complications arising from spillage of gall stones during laparoscopic cholecystectomy are extremely rare. They can present months or years after the cholecystectomy with septic complications not necessarily located in the right upper quadrant.

The surgeon should take utmost care to prevent spillage of stones and attempt to remove all visible stones at the time of surgery. If spillage occurred it should be recorded clearly in the operative notes and there is no indication for routine conversion to open surgery. Patients should be informed to minimise any legal implications, and to aid in the early diagnosis of later complications.

REFERENCES

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Gall bladder Stones Hospital – Treatment, Removal Surgery

About Gall Bladder Stones :

Gallbladder is a small, pear-shaped organ, located at the upper right part of the abdomen below the liver.

The role of the gall bladder is to store the yellow coloured liquid called bile juice that helps in proper digestion.

Whenever there is  excessive cholesterol deposit, it  gets hardened and forms Gallstones. These are of varying sizes ranging from the size of a grain to the size of a golf ball. Also, there may be multiple gallstones present at the same time. 

If a person feels severe symptoms of gallstone, he/she is advised to undergo gall bladder stone removal surgery. Otherwise, if these stones do not cause any problems, there may not require any treatment.

 

Types of Gall Bladder Stones :

There are basically Two Types of Gallstones :

• Cholesterol stones: Usually yellow-green in colour, they are the most common gallstones found. Excessive concentration of bile in gall bladder leads to formation of yellow cholesterol stones.

• Pigment stones: Small and darker ones, these stones are formed of bilirubin. Bilirubin   comes from bile which is produced by the liver and gets stored in the gallbladder.

On this page:

Gall bladder Stones Causes :

There is no clear thought on what exactly leads to the development of gallstones. However, there are a few theories, based on which doctors carry forward the treatment.

Presence of Excessive Cholesterol in Bile : Bile present in gallbladder has the ability to dissolve the cholesterol released by our liver. However, if the quantity of cholesterol released is much more than the bile can process, the excess cholesterol crystallizes and turns into hard yellow coloured stones.  

Presence of too much of Bilirubin in Bile : Bilirubin is a chemical produced by the liver on break down of the red blood cells. Sometimes, the liver tends to produce excessive bilirubin due to certain medical conditions like biliary tract infections, liver cirrhosis, and few blood disorders.  This excess bilirubin leads to the formation of gallstones.

Gallbladder not working Efficiently : There may be conditions when the gallbladder does not empty completely as it should. In that case, bile gets accumulated and concentrated and leads to stone formation.

Gall Bladder Stone Symptoms :

In most cases (75%), gallbladder stones show no signs or symptoms.

Often, gallstones do not show any symptoms, but when it gets stuck in the duct, it can cause blockage. In that case,   you can experience one or more of the following symptoms:

• Sudden acute pain in the upper right side of the abdomen
• Back pain between the shoulder blades
• Pain in the right shoulder
• Nausea/vomiting
• Dark urine
• Burping
• Diarrhoea
• Indigestion/acidity

Gall Bladder Stone Pain :

Gallbladder pain due to stones is sudden and intensifying. One may experience it in the middle or upper right section of the abdomen, or one may feel pain in the back at the middle of shoulder blades. 

This pain may last for a few minutes or a few hours. It may get less intense or disappear to reappear. This pain is probably caused when a gallstone blocks the passage of bile that gets passed through gallbladder to the small intestine.

How Gall Bladder Stones Diagnosed?

There are several traditional and advanced procedures and tests that help doctors diagnose the condition and degree of the disease.

• Physical Examination : The doctor will conduct physical examination by checking your eyes and skin for change in colour as a yellowish tint can indicate signs of jaundice. 
• Ultrasound : Preferred imaging method to see the presence of gallstones and abnormalities due to acute cholecystitis.
• Abdominal CT Scan : An imaging test that provides images of your liver and abdominal area.
• Gallbladder Radionuclide Scan : Very effective test. It takes around one hour to complete. During this test, a radioactive substance is injected into your veins that travel to the liver and gallbladder via blood.  Results of this test suggest the presence of blockage and infection in the bile ducts from stones.
• Blood Tests : Tests the amount of bilirubin and how the liver is functioning. 
• Endoscopic Retrograde Cholangiopancreatography (ERCP) : During this procedure, a camera and X-rays are used to determine the problems in the bile a pancreatic duct.

How are Gallstones Treated?

Commonly, Gallstones require no treatment unless they cause severe symptoms like pain, and vomiting etc. Surgery is recommended in severe cases. 

a.) Surgery :

• Laparoscopic Gallbladder Removal : During this procedure, the surgeon will make 3-4 incisions in your abdomen. Through these incisions, a small, lighted device is inserted to carefully remove the gallbladder.  The patient isrelieved on the same day of the procedure if no further complication is seen.

b.) Nonsurgical Treatments :

• Medication : Due to advanced surgical procedures using laparoscopic and robotic techniques, surgeries are a lot easier and successful these days. Still, if you are not a candidate for surgery due to certain medical complications, doctors may prescribe a few medications that help dissolve these gallstones. But, medications are not commonly recommended as they are not much effective in treating this problem and take years to show results.

Gall Bladder Stone Diet :

a) Effect of Food on Gallbladder : Being a small, delicate yet important organ, it is important to consume a healthy diet full of nutrients to maintain its health. While some foods help in improving its function, others can initiate and aggravate the gallbladder problems. 

b) Foods – Good for Gallbladder : The key to having a healthy gallbladder is to have a well-balanced diet having fruits, and vegetables, which have loads of nutrients, high in calcium, vitamins C, and B and fiber. Also, eating plant-based protein like beans, nuts, lentils, tofu, and tempeh are very good for gallbladder. 

It is best to Incorporate Following Foods in Your Diet for a Healthy Gallbladder :

• Dark, leafy greens
• Tomatoes
• Bell peppers
• Citrus fruits 
• Milk
• Low-fat dairy
• Fish and shellfish
• Sardines
• Nuts
• Beans
• Tofu
• Lentils

Foods Not Good for Your Gallbladder :

It is best to avoid the foods which are high in fat and processed foods.  Vegetable oils are difficult to break down and cause gallbladder problems.

• Refined white foods (bread, pasta, etc.)
• Vegetable oil
• Processed foods
• Peanut oil
• Foods high in fat

Gall Bladder Stone Risk Factors :

There is not much information about the exact causes of formation of gallstones. Still, there are some observances about risk factors of formation of gallstones. 

Women are observed to have more tendencies to develop this problem. Moreover, pregnant women, women on hormone replacement therapy, and those using hormone birth control are  at increased risk of having gallstones.

Besides, there are other risk factors which are common to both genders. These are as follows :

• Coronary artery disease
• A history of gallbladder problems;  self or in family
• Excess weight
• Rapid weight loss followed by weight gain
• Diabetes
• A faulty diet that is  high in processed foods, carbohydrates and calories but having lowfibre
• Lactose intolerance
• Having cirrhosis
• Taking certain medications for lowering cholesterol

When to see a doctor?

When a gallstone blocks the duct from where gallbladder releases the bile, it can lead to serious problems like inflammation and infection. It is called acute cholecystitis and is a medical emergency. 

The Symptoms associated with the condition are as follows :

• Intensifying pain in the upper right side of the abdomen or mid-right back
• Fever/chills
• Nausea/vomiting
• Appetite loss

Other conditions that may arise due to untreated gallstones are as follows:

• Jaundice
• Pancreas inflammation
• Gallbladder cancer
• Cholangitis, a bile duct infection
• Sepsis, a blood infection

Gall bladder Stones FAQs (Frequently Asked Questions) :

Are Gall bladder stones Serious?

A gallstone may cause a serious condition when a small sized stone  blocks the bile duct. The conditions may include Cholecystitis (gallbladder inflammation), Pancreatitis (inflammation of the pancreas), Jaundice and/or Cholangitis (inflammation of the liver).

Can Stone be Removed from Gallbladder?

Medications (including Ursodeoxycholic acid), Lithotripsy (breaking down of gallstones through shock waves and Laser), ERS or Endoscopic Retrograde Sphincterotomy (for relief from obstruction), and Cholecystectomy (surgical removal of the gallbladder) are the methods used for removing gallbladder stones.

What foods to avoid if you have gall bladder stones?

One should avoid food high in cholesterol and fat during the gallstone condition. A diet high in fruits and vegetables, whole grains, low-fat dairy products, and lean meat/ poultry/ fish, which is high in fiber, is good for gallstone condition.

 

Can you dissolve gall bladder stones?

Medications including ursodiol and chenodiol can dissolve the cholesterol gallstones, but it may take years for them to produce the desired effects.

Can apple juice dissolve gall bladder stones?

Apple juice contains malic acid, which may soften the gallstones. No scientific studies actually support the claim.  Consumption of excessive fruit juices can be detrimental to health. Talk to your physician before using any such natural remedy.

Is it possible to remove gall bladder stones without surgery?

The gallstones can be removed without surgery by methods including Lithotripsy and shock wave therapy, medications, and endoscopy treatment.

What is the best treatment for gallbladder stones?

If gallstones occur frequently, surgery is the recommended treatment option, which is the removal of the gallbladder. Medications are used in people who cannot undergo surgery, and it may take years to give results.

Which doctor treats gallbladder stones?

A Gastroenterologist treats gallbladder stones. You may also be referred to a surgeon for Cholecystectomy or surgical removal of the gallbladder.

How can I dissolve gall bladder stones naturally?

While a number of claims have been made that the gallstones can be dissolved through natural remedies including Apple juice, apple cider vinegar, milk thistle, and others, no conclusive evidence has been found towards the effectiveness of these remedies. Only trust your registered and certified doctor for providing you the best and reliable treatment.

Can gallstones come back after the gallbladder is removed?

Gallstones may not be formed in the gallbladder as it is surgically removed, but it still can form in the other structures located within the biliary tract (for instance, the common bile duct). But such incidences are very rare.

Can you remove gallstones without removing the gallbladder?

Medications can dissolve the cholesterol gallstones over a period of a few years. Lithotripsy or extracorporeal shockwave treatment can be used in patients not having enough strength for gallbladder surgery.

OBSERVATIONS ON SOME CAUSES OF GALL STONE FORMATION | Journal of Experimental Medicine

As previous papers from our laboratory have shown, there exists a well defined tendency for calcium carbonate to come out of solution in the normal liver bile of the dog, and for it to be deposited on certain nuclei not infrequent in the secretion under pathological circumstances. Gall stones that had arisen in this fashion were a frequent occurrence in the intubated animals we studied. The present paper is concerned with the reasons for the absence of such stones from dogs with an intact biliary tract.

The solubility of calcium carbonate is known to be markedly affected by the reaction of the fluid in which it is contained. The normal liver bile, out of which it tends to precipitate, is alkaline, with an average pH of 8.20 but in the gall bladder where conditions might otherwise seem especially favorable to precipitation, the secretion undergoes a change toward the acid side, becoming on long sojourn there, strongly acid to litmus (pH 5.18 to 6.00). From bile as thus altered, no carbonate precipitation takes place, even when it becomes greatly concentrated as in fasting animals or after obstruction of the common duct. Furthermore, carbonate which has precipitated out of liver bile on standing dissolves again in it when the fluid is rendered slightly acid in vitro, or, in some cases merely neutral to litmus.

There are several obvious reasons for the absence of carbonate stones from the normal ducts under ordinary conditions,—notably the motility of these latter, the flushing that they undergo from an intermittently quickened bile stream, and the cleansing and possibly antagonistic action of the secretion elaborated by the duct mucosa. In the fasting animal, one at least of these influences is almost done away with, the rate of bile flow is so greatly cut down; while furthermore the calcium concentration of the secretion undergoes a considerable increase. But pari passu with these changes there occurs one in the bile reaction, a diminution in alkalinity so great that the pH often approximates that of the neutral point for litmus. That this change is not a direct consequence of the increase in calcium, may be inferred from the findings with stasis bile, the calcium content and reaction of which were observed to vary independently, if in general in the same direction.

These adjustments within the organism, some of which may be thought to exhibit an element of the purposeful, when considered with the test-tube experiments, strongly suggest that the reaction of the bile plays a critical part in determining the occurrence of carbonate stones, as furthermore that their absence from the normal gall bladder is a consequence of the changes in the bile reaction there occurring. The changes come about through a functional activity of the bladder. This being the case, one might suppose that the failure to act would be followed by a formation of carbonate stones. There is sufficient evidence available in the literature to indicate that this happens, in rabbits at least.

It is important to know whether changes in the bile reaction play any part in determining the cholelithiasis of man. To determine the matter will require a large material. But this much we have shown, that carbonate spheroliths not infrequently serve in human beings as centers in a formation of secondary stones of carbonate and cholesterol, as further that cholesterol precipitation out of human bladder bile can be induced or prevented by slightly altering the reaction of the fluid toward the alkaline and acid sides, respectively.

The possibility that cholelithiasis may be a consequence of sins of omission on the part of the biliary channels and reservoir deserves to be considered.

Gallstone Surgery Video | Lap Cholecystectomy Surgery Video

The gallbladder is a pear shaped organ located on the right side of the abdomen, just below the liver. It stores bile fluid which is produced in the liver. Bile fluid contains water, proteins, fats, cholesterol, bile salts and bile pigments, which aid in the digestion of food. The gall bladder releases bile fluid into the intestine through the common bile duct following ingestion of food.

An imbalance in the components that form bile can lead to the formation of gallstones. Gallstones are small, hard deposits that form inside the gallbladder. The size of the gallstone can range from a small grain of sand to a large golf ball.

Gallstones are of two types:

Cholesterol stones: These are yellowish-green in color and chiefly made up of hardened cholesterol.

Pigment stones: These are dark and small, usually present in numbers and primarily made of bilirubin, a yellowish bile pigment.

In some cases, a mix of both gallstone types can be seen.

Causes.

The exact cause of gallstones is not clear. However, gallstones can form due to increased amounts of cholesterol or bilirubin; or inadequate emptying of the gallbladder.

The risk factors that increase the chance of having gallstones include:

Pregnant women and women taking birth control pills or hormone replacement therapy.

Elderly people (>60 years).

Genetic factors & family history of gallstones.

Ethnic background, esp. native Americans and Mexican-Americans.

Diabetes.

Obesity.

Rapid weight loss.

Use of cholesterol-lowering drugs.

Signs and Symptoms.

Gallstones do not always cause symptoms, and are sometimes called ‘silent stones’. These are often detected by your physician while diagnosing another condition. However, when the gallstone moves and lodges itself in the bile ducts, it causes signs and symptoms such as:

Pain in the upper abdomen, upper back, and between the shoulder blades; lasting for several hours.

Nausea & Vomiting.

High fever with chills.

Yellowing of skin and eyes.

Other gastrointestinal problems such as bloating, indigestion, and heartburn.

Complications.

The complications of gallstones include:

Blockage of the common bile duct leading to jaundice and infection.

Blockage of the pancreatic duct leading to pancreatitis.

Gallbladder inflammation (cholecystitis).

Increased risk of gallbladder cancer.

Diagnosis.

Your physician diagnoses gallstones based on your symptoms, medical history, and physical examination. The diagnosis is confirmed based on findings from imaging studies such as ultrasound, CT (Contrast Tomography), MRI (Magnetic Resonance Imaging), and ERCP (Endoscopic Retrograde Cholangio Pancreatography) which helps to locate gallstones in the gallbladder as well as bile ducts. Your doctor may also request blood tests to any complications of gallstones.

Treatment.

Gallstones without symptoms do not require treatment. Treatment for symptomatic gallstones and its complications includes medications to dissolve the gallstones, and surgery to remove the gall bladder (cholecystectomy).

Medications can help dissolve gallstones but may take several months to years, so this option is reserved only for patients contraindicated to surgery.

The surgical removal of the gallbladder does not cause any serious problems as it is not necessary for you to live. Surgery is also recommended as gallstones can reoccur. Once the gall bladder is removed, the bile is directed from the liver into the intestine.

Gallstones are hard deposits of bile fluid in the gallbladder, primarily composed of either cholesterol or bilirubin. Gallstones may not cause any symptoms or may cause severe abdominal pain, vomiting and fever. When symptomatic, medications and surgery to remove the gallbladder are the two mainstay methods of treatment.

Intrahepatic type II gall bladder perforation by a gall stone in a CAPD patient | European Journal of Medical Research

A perforation of the gall bladder currently arises in 0.8-3.2% of the cases with acute onset of cholecystitis, but there is no data about the incidence of gall bladder perforation in chronic cholecystitis. Most cases present with a rupture into the peritoneal cavity. Development of an intrahepatic abscess represents a rare complication and is reported in literature only by several case reports. Both, perforation of the gall bladder or pyogenic liver abscess represent a life-threatening complication with mortality rates of 7% [4] and 5.6% [9] as shown by retrospective studies.

Gall bladder perforation is divided into three categories accordingg to progress (acute – subacute – chronic) and type of perforation (into free abdominal cavity – development of pericystic abscess – development of fistulae). This classification was described first by Niemeier in 1934. With regard to the histologically proven chronic-recurring cholecystitis and the development of an intrahepatic abscess this case has to be classified as a type II perforation. The incidence of clinical symptoms is variable and may be absent in chronic or subacute progression of disease. The performance of an abdominal ultrasound is an essential part of the work up of patients with fever and abdominal pain. In asymptomatic patients or cases with just mild abdominal pain gall bladder perforations may be diagnosed solely by imaging procedures.

Only two studies from 1994 and 2002 with low numbers of patients (combined n = 31) compared diagnostic findings between ultrasound and computed tomography in patients with gall bladder perforation. In comparison to the CT-scan, ultrasound seems to be less sensitive with 70% vs. 80% for the detection of the perforation [10, 11]. Nevertheless, with regard to the improvement of resolution of modern sonographic imaging equipment, better results can be expected today. Therefore, abdominal ultrasound represents a reliable tool as imaging of first choice. CT scans are needed in cases of discrepancies between clinical symptoms and inconspicuous ultrasound as well as for better pre-operative planning subsequently to the sonographically proven perforation. CT scans have the advantage of a better representation of extensive findings because of the bigger field of view (FOV) and may demonstrate the extension of a lesion more clearly.

Patients who need CAPD show a significant higher incidence of peritonitis in comparison to the general population [12]. Nevertheless, there is no evidence in the literature that patients with CAPD show a higher incidence of cholecystitis or risk of gall bladder perforation than the general population even if some studies demonstrate that the prevalence of cholelithiasis may be higher in patients with dialysis than in non-dialysed control groups [13–16]. Analysis of the peritoneal fluid in this patient showed no white blood cells and lack of bacterial growth in culture. Therefore it seems to be unlikely that the peritoneal fluid was the origin for bacterial infection of the gall bladder. The onset of an acute on chronic cholecystitis with the development of a gall bladder perforation represented an independent disease with no relation to the continuous ambulatory peritoneal dialysis.

Interestingly, Murphy’s sign as a clinical evidence of peritonism was not detectable. Usually, palpation of the gall bladder is painful when inflamed peritoneal layers rub on each other. However, when free fluid is present – as it is in patients with peritoneal dialysis – peritoneal layers are separated and Murphy’s sign may vanish. Secondly, peritoneal layers may not have been affected in this patient because this was a covered perforation into the liver.

In conclusion, the present case shows that life threatening gall bladder ruptures have to be considered in patients with fever and only mild abdominal symptoms. In these patients ultrasound is a reliable tool to diagnose gall bladder perforation and avoids delay of treatment.

Seals, nodes in the mammary gland

11/17/2021

The article was checked by a doctor-mammologist of the highest category, Ph.D. Zorina E.Yu. is for general informational purposes only and does not replace specialist advice.
For recommendations on diagnosis and treatment, a doctor’s consultation is required.

In the Yauza Clinical Hospital, highly informative and safe methods (digital low-dose mammography, ultrasound, MR mammography, ductography, histological examination of biopsy material, etc.) are used to assess the condition of the mammary gland and to identify the presence and causes of lumps or nodes.In case of revealing pathological formations, the specialist will prescribe a complex treatment – effective drug therapy, if necessary – surgical intervention.

Does a lump in the chest always indicate a pathological process? Nodal formations associated with hormonal changes in the body (pregnancy, lactation, menopause, etc.) can disappear on their own with the normalization of hormonal levels. In other cases, our mammologists, after a thorough diagnosis, will prescribe and carry out treatment.

Causes of seals, nodes in the mammary gland

The appearance of seals in the mammary gland may be associated with an imbalance against the background of the use of contraceptive drugs, pathological dysfunctions of the thyroid gland, ovarian dysfunction, mastitis. Injuries, bruises of the chest, stress lead to the formation of nodes. The consequence can be abortion, menopause, reproductive system disorders. You cannot wear a tight bra.

The seal can be as small as a pea or as large as a grapefruit.Small size is not a reason to ignore the problem. Often, small neoplasms grow to gigantic proportions in a short time. If you find you have a lump in your chest, make an urgent appointment with your doctor. Perhaps it will save your life and, for sure, keep your health.

Inflammatory diseases

The more common inflammatory pathologies of the mammary glands include mastitis caused by staphylococci.

Types of mastitis:

• Non-lactation.Has an acute or chronic form. Develops with bruises, hypothermia, burns.
• Lactation. The consequence of lactostasis during breastfeeding.
• Galactophorite. Inflammation of the ducts.
• Purulent. Abscess or phlegmon of the mammary gland, followed by the formation of a seal.
• Non-purulent. Inflammatory process with serous tissue sweating.

Mastitis is accompanied by pain, tissue swelling, induration, fever, weakness, signs of intoxication.

Specific infections

Nonspecific breast infections include tuberculosis and syphilis. With tuberculosis, there is hypertrophy and thickening of the breast, flushing of the skin and an increase in regional lymph nodes.

Syphilis of the mammary glands is rare, has a long course and is characterized by systemic damage to the body. It develops in three stages. The causative agent is a pale spirochete that penetrates through microcracks and has the ability to reproduce rapidly.The disease is contagious at any stage. This type of syphilis is not transmitted to men.

Traumatic injury

Chest injuries are common among women of all ages. The bruises are accompanied by aching and severe pain. Damage can be open or closed. The traumatic factor leads to damage to blood vessels and the outpouring of blood into the tissue, as a result of which hematomas are formed with clear boundaries of blue or maroon color.

If the areola or nipple area is bruised, traumatic shock may occur.Open wounds pose a risk of infection.

Consequences of diseases, injuries and operations

The seals formed after a bruise are not malignant, but can be reborn later. Especially dangerous are chest injuries if a woman has nodular mastopathy. In case of untimely access to a doctor, dangerous complications develop.

These include:

• Fat necrosis. Focal death of breast tissue, with the appearance of a painful compaction.There is a deformation of the breast, skin retraction and a change in its color. A benign formation does not degenerate on its own into a cancerous tumor, but it can become a provoking factor.
• Calcifications. Calcification of the soft breast tissue. The accumulation of calcium salts in the mammary gland develops against the background of any disease, including cancer (in 20% of cases). On palpation, they are found with an increase of more than 1 cm.
• Capsular contracture.Growth of fibrous tissue around the implant after mammoplasty. Compression of a foreign body leads to deformation of the breast, the appearance of a seal in the area of ​​the gland, contouring of the implant, and discomfort.
• Polyacrylamide gel knots. Complicated condition after breast plastic surgery using polyacrylamide gel. There is a transformation of the gel into capsules in the form of subcutaneous seals, movement to other parts of the body. The development of a massive inflammatory process with purulent discharge is possible.

Breast contusion is accompanied by the formation of swelling and pain. Sometimes injuries result in clear or bloody discharge from the nipple. Any breast should be a reason for contacting a mammologist for a detailed diagnosis.

What do the pains indicate?

In most women, a burning sensation and a dull pain in the chest is a consequence of premenstrual syndrome. A burning sensation and chest pain occurs early in pregnancy.

Compaction and soreness in the breast occurs when milk accumulates in the mammary glands in a nursing mother. With the formation of cracks in the nipples, there is a risk of infection and the development of mastitis.

Localized pain and burning sensation in the chest can be the cause of the development of benign lesions. This pain increases in a certain position of the body.

Burning and pain in one side of the chest may indicate the development of cancer.Breast tumors are more often located in the upper outer quadrant.

Types of breast seals

Breast neoplasms are of several types. Each of them has certain symptoms.

Mastopathy

More about forms of mastopathy:

• Fibrous. A benign formation that occurs in glandular or connective tissues. Degeneration into a malignant tumor is possible.
• Fibrocystic. Formations of a benign nature. It is manifested by changes in the consistency of the mammary gland, cyclic pain, the formation of fibrosis and cysts, due to the reaction of breast tissue to hormones, estrogens and progesterone.
• Nodal. Benign dysplasia with pronounced centers of compaction (nodules). It develops due to hormonal imbalance and is characterized by excessive formation of connective tissue in the chest.
• Adenosis. It is a form of fibrocystic mastopathy, in which there is an increase in glandular tissue. The main symptoms: pain, the formation of seals, nipple discharge, breast engorgement.

Benign breast tumors

• Fibroma. A dense, painless, benign nodular seal. Before menses, there is a feeling of fullness in the chest. Seals can be single or multiple, well demarcated and flexible.The size varies from a few millimeters to several centimeters.
• Adenoma. Benign growth, which can be caused by hormonal imbalance. The tumor grows from epithelial cells and is diagnosed before the age of 40. Usually located closer to the surface of the gland in the form of a mobile, elastic spherical seal.
• Fibroadenoma. It has a benign character and belongs to the form of nodular mastopathy. It develops from glandular tissue.In 5% of cases, it poses an oncological threat. More common in women of reproductive age. It manifests itself in pain and discomfort.
• Lipoma. Represents a benign dense formation in the structure of the breast, originating from adipose tissue. The tumor is round, elastic and mobile.
• Fibrolipoma. The lump consists of fibrous and adipose tissue. It is felt as a movable, compacted assembly. With a long course of the disease, symptoms are completely absent.Increasing in size, it causes deformation of the breast, sometimes calcification. Degeneration into cancer is very rare.
• Galactocele. Cystic formation filled with milky contents. At the initial stages, the clinical picture of the disease is absent. The enlargement is accompanied by discomfort and deformation of the breast. Signs of toxicity may be present.
• Intraductal papilloma. Refers to benign formations.It is localized in the dilated sections of the breast ducts, under the areola, near the nipple. It is a papillary wart on the duct wall. It is easily injured and bleeds, resulting in copious yellow-green, brown or milky discharge from the nipple.

Leaf tumor

A leaf-shaped tumor has a fibroepithelial nature and carries the potential danger of developing a malignant formation. It differs in two phases of development: a long course (sometimes takes several decades) and dynamic development.

The formation is localized in the center of the breast or in the upper part, spreading to the entire mammary gland or most of it. With the development of malignancy, the lungs, liver and bone tissues are affected. The lymphatic system is not inflamed. It is characterized by a tendency to relapse.

Malignant tumors of the breast

• Hormone-dependent cancer. A malignant neoplasm that develops from glandular tissue, the cells of which contain specific receptors that are sensitive to progesterone and estrogens.It is characterized by an increase in regional lymph nodes, nipple discharge, diffuse or limited compaction in the chest area, changes in the skin and shape of the mammary glands. Symptoms of tumor intoxication are observed.
• Breast cancer in pregnant women. Malignant tumor detected during pregnancy, lactation or within a year after the birth of a child. Symptoms appear in the form of diffuse or nodular thickening of the mammary glands, enlargement of the axillary lymph nodes.Patients are worried about soreness, heaviness and discomfort in the chest. Uncharacteristic discharge from the nipple and local changes in the skin are observed.
• Three times negative breast cancer. The most aggressive type of malignant neoplasm, in which the tumor cells lack targets for attack (progesterone, epidermal growth factor, estrogen). A dense volumetric node is formed, regional lymph nodes increase, changes in the skin are observed, the mammary gland is noticeably deformed, and discharge from the nipple appears.
• Hereditary cancer. The development of a tumor is associated with genetic changes that have been inherited through a female or male cell from their predecessors and are associated with an increased risk of the disease.
• Recurrent cancer. A type of cancer that develops after a period of remission in which no abnormal cells have been found in the body. Relapses are more dangerous than the primary tumor. As a serious complication of cancer, they have a more toxic effect on the body.
• Cancer of Paget. A form of malignant formations of the mammary gland, in which the nipple and areola are affected. A lump is felt in the chest, soreness, itching, and burning appear. The nipple is deformed, yellow or bloody discharge appears. The peri-nasal region is easily injured, bleeds, and becomes crusty. Axillary lymph nodes are enlarged.
• Invasive ductal carcinoma. It is one of the most common types of breast cancer.It begins to develop in the milk ducts of the breast, can break out of the ducts and penetrate into the surrounding tissues. Symptoms of the disease are manifested in the form of swelling and pain in the chest, retraction of the nipples.

Breast sarcoma

Sarcoma in its morphology is a tumor of connective tissue origin, not epithelial. It accounts for approximately 0.2-0.6% of all malignant neoplasms. It can be found at any age.

In the initial stages of development, most malignant neoplasms do not give pain.Therefore, even if the seal does not cause discomfort, you should definitely visit a doctor to determine the nature of the pathology. Make an appointment with a specialist to protect yourself from serious illnesses.

Mastitis

Mastitis is an inflammatory disease of the mammary gland that occurs as a result of the penetration of an infection (Staphylococcus aureus, Streptococcus) mainly through cracks in the nipple when feeding a baby. It most often develops in lactating women in the postpartum period, and may also not be associated with lactation.With mastitis, inflammation of the lactiferous ducts occurs, while milk may be excreted with an admixture of pus. The appearance of compaction and nodular formation in one or more lobules of the mammary gland is observed. A movable, painless seal with clear boundaries is palpated.

Breast cysts

A breast cyst is a pathological cavity that is filled with liquid contents. It is manifested by aching pain, which is associated with an increase in the formation, which squeezes the surrounding tissues.

Hyperplastic breast lobules

A hyperplastic lobule of the mammary gland is an increase in the proportion of the mammary gland. It occurs mainly during pregnancy and can cause the development of fibrocystic mastopathy. No treatment required.

Diagnostics of the causes of seals, nodes in the mammary gland

• Consultation with a mammologist. A mammologist will examine the patient, palpate, revealing a seal, a node, prescribe all the necessary examinations and, if necessary, send for consultation to other specialists of our center – an oncologist, gynecologist, genetics, endocrinologist, surgeon.
• Instrumental studies :
  • Ultrasound of the mammary glands;
  • ductography;
  • digital and MR mammography.
• 3. Laboratory research:
  • biopsy followed by histological examination;
  • cytological examination of a smear of discharge from the breast;
  • determination of hormonal levels;
  • Genetic study to determine the risk of developing breast cancer.

If, as a result of the examination, this or that pathology was revealed, the mammologist will draw up an individual treatment program.

Most breast lumps are not ultimately cancerous. However, to be sure of this, you need to undergo a high-quality examination. By making an appointment now, you will have the opportunity to undergo diagnostics using the latest equipment at a convenient time for you.

Treatment of seals, nodes in the mammary glands

Treatment for breast lumps and nodules depends on the cause.The exception is a hyperplastic lobule, which is a variant of the norm and does not require treatment. But observation by a specialist with such a diagnosis is necessary.

In other cases, we use:

• conservative therapy;
• Surgical treatment: abscess opening, sectoral breast resection without breast removal in benign tumors; radical resection (with the underlying areas of muscles and fascia) or mastectomy with the removal of regional lymph nodes in malignant processes, later plastic reconstructive and aesthetic surgeries are possible;
• chemotherapy for malignant neoplasms.

Self-examination, which must be carried out regularly, is of great importance for the early detection of breast pathology. If you find lumps in your breasts, see a specialist. The success of treatment directly depends on the early diagnosis of the disease. Doctors at the Yauza Clinical Hospital will identify the cause and help you cope with any breast disease.

Cost of services

You can see prices for services in the price list or specify by phone, indicated on the website.

Which doctor should I go to for examination?

You should know that mastopathy and mastitis can cause the development of oncology. Regular examinations by a specialist will help to avoid dangerous pathology. In case of pain and seals in the area of ​​the mammary glands, you should contact a mammologist. After an accurate diagnosis, he will prescribe the appropriate treatment.

For prevention purposes, it is recommended to visit a mammologist annually. With burdened heredity, due to individual characteristics, in the presence of concomitant pathologies, additional visits to the doctor are required.

What symptoms do you need to see a doctor urgently?

If the following signs appear, you should seek the advice of a specialist:

1. Aching pains in the chest and mammary glands.
2. Well palpable lumps in the chest.
3. Stagnation of breast milk during lactation, changes in its color and smell.
4. The formation of weeping wounds on the skin.
5. Foul-smelling nipple discharge.
6. A sharp change in the size and shape of the mammary glands.
7. Itching of the nipples and any change in their appearance.

It is impossible to postpone the visit to the doctor if breast edema appears after implantation. Patients with chronic sexually transmitted diseases must undergo routine examinations. A regular visit to a mammologist is indicated for women with a burdened heredity. Injuries to the chest can lead to cysts or tumors.

FAQ

Can a cyst or other benign breast mass develop into cancer?

Any benign formation in the breast is not regarded in medicine as a precancerous condition, but is a risk of the subsequent development of oncology. The impetus for the formation of a cancerous tumor can be concomitant factors or an advanced stage of the disease.

Which doctor should I contact if I have a lump in my chest?

A gynecologist can only conduct an examination by palpation and refer for consultation and further diagnosis to a mammologist.

Should you be afraid of mammography?

You should not be afraid of mammography. X-ray diagnostics takes no more than 10 minutes and allows you to identify even minor changes in the initial stages of development.

Should I see a doctor or, since it doesn’t hurt, will it “go away by itself”?

Many breast lumps are benign (8 out of 10) and do not pose a threat.But without consulting a doctor, the patients themselves cannot assert this. It is possible to cope with any malignant formation only if it is detected in the early stages. If you detect any changes or the appearance of chest pain, you should immediately consult a doctor.

If breast examination shows changes, how can you be sure it is not cancer?

Only a doctor after the examination can give an answer. Benign formations are characterized by mobility and painlessness in the early stages.

What needs to be done in order not to miss the onset of breast disease?

Successful treatment of breast pathologies depends on the stage at which the disease was detected. A good chance not to miss the beginning of the development of education is self-diagnosis and regular visits to the doctor. Self-examination helps to identify the first changes.

Does pain cause cancer?

Malignant tumors in the chest in the early stages do not have symptomatic manifestations.Painful sensations appear during the degeneration of tissues into cancer and become intense and pronounced at a later date with the growth of the neoplasm.

Literature:

3. Semiglazov V.F., Ailamazyan E.K., Baylyuk E.N. Prevention of breast cancer in patients with proliferative processes of the reproductive system // Problems of Oncology.2006.

4. Bershtein L.M., Boyko A.V., Borisov V.I. Algorithms for the scope of diagnosis and treatment of malignant neoplasms of hormone-producing and hormone-dependent organs // Moscow. 2003.

90,000 Petersburg court blocked the anime “Death Note” and “Tokyo Ghoul”

The distribution of the anime Death Note, Inuyashiki, Tokyo Ghoul and Elven Song was banned on two sites due to the lack of an 18+ mark.A judge at the Kolpinsky District Court in St. Petersburg found appeals to suicide, violence and homosexuality in the films. Daria Lebedeva, head of the united press service of the city’s judicial system, commented on the bans for Gazeta.Ru.

At a meeting of the Kolpinsky District Court of St. Petersburg, the distribution of several anime films on two Russian-language sites was prohibited. In particular, the TV series Death Note and Inuyashiki were banned. Judge Dmitry Nikulin concluded that both animes pose a threat to the psyche of children.

“Demonstration of violence on the screen, permissiveness, blurred ideas about good and evil leads to the fact that the child’s psyche is deformed. In fact, now Russia is faced with depopulation, because whoever brings offspring in the future – those who are growing now – quotes him “Mediazona” .

– The younger generation is the main human potential. And we lose it because of such films. In different directions – both homosexuality and suicide “..

The judge also ordered to block a page with “Tokyo Ghoul” on one of the sites.This anime is about a student who has become a half-creature called a ghoul, eating people for survival. According to Nikulin, the court was unable to identify the defendant because the site’s domain is based abroad.

“When we watched the first episode of Tokyo Ghoul, we saw the presence of scenes with the separation of body parts and their consumption,” the judge read out the expert’s ruling. – In this series, an attitude towards sadistic inclinations is practically formed. It is easy to grow a sadist out of such a person.You have to understand that we have a lot of hidden psychopathology. ”

For similar reasons, the court granted the claim to ban the film “Elven Song”. In addition, Nikulin planned to examine Morgenstern’s song “I ate my grandfather” for calls to illegal actions. According to the source, the judge could not find the lyrics and postponed the hearing on this lawsuit until February 17.

Roskomsvoboda lawyer Sarkis Darbinyan said that after the judge announced a specific reference to the film, the case materials were sent to Roskomnadzor.The federal service then notifies the site owner to remove the objectionable content.

“And if it doesn’t delete it … It’s clear that everyone works on https, the RKN cannot block page by page, so providers begin to block the entire domain. Further, if this video begins to circulate, then, of course, it requires a new court decision – unless it is a mirror of the site itself, “Darbinyan shared.

Head of the United Press Service of the St. Petersburg Judicial System Daria Lebedeva answered the question “Newspapers.Ru ”about whether it makes sense to block pages with films on a limited number of sites.

“The water wears away the stone,” said a spokeswoman. – The main reasons for blocking were the absence of the mark “18+” and the possible inducement of children to unlawful actions. In court, it was about children ”.

According to Lebedeva, access to links with prohibited content will be completely blocked in Russia, regardless of where the domain is registered.

“It doesn’t matter, Roskomnadzor is quietly blocking all this on the territory of our country.Fighting the potential use of VPNs and other workarounds to access prohibited content is not our question, ”she added.

In December, the joint press service of the city courts of St. Petersburg announced the plans of the Kolpinsky District Court to investigate “the harmful influence of Japanese anime on the minds of the children of the Russian Federation.” According to the Telegram channel of the press service, the court registered five administrative lawsuits for the recognition of information on 49 links prohibited on the territory of Russia.

A week before the meeting, a St. Petersburg schoolboy tried to commit suicide, imitating the protagonist of Death Note.The boy was sent to intensive care.

Gulya Gaifieva, Deputy Chairman of the Our Mountains movement (Severouralsk), asks the Minister to transform the Denezhkin Stone Reserve into a National Park

Vadim Averyanov, a public figure, deputy chairman of the Regional Public Organization “Protection of Nature”, spoke about this in his blog.

“At the personal reception of the Minister of Natural Resources of the Sverdlovsk Region Alexei Kuznetsov, held last Friday in Severouralsk, the deputy chairman of the movement“ Our Mountains ”Gulya Gaifieva handed him an appeal, which, in particular, says:

“Dear Alexey Vladimirovich!

I am writing to you regarding the need to develop ecological tourism in the North of the Urals.The Denezhkin Kamen mountain is located not far from Severouralsk. Having become a point of attraction for tourists from all over the country, the Denezhkin Kamen reserve will lay the foundation for the development of a transport interchange between Severouralsk and other Russian cities. Hotels and cafes may appear on the territory adjacent to the reserve, and this will provide the city with additional jobs.

For example, in the city of Krasnoyarsk there is a specially protected natural area (SPNA) “Stolby”. And today “Stolby” is in the status of a reserve and at the same time is an exception to the rules due to the historically established tradition of visiting the rocky area, an individual zoning scheme was made for its entire territory: a protected zone, a strictly protected area, a tourist-excursion area and a buffer zone, which, according to the Federal Law, corresponds to the structure of the national park.
I am a native of Severouralsk. In school years, we could not imagine how not to go on a hike with a class to Staraya Kalya, Devil’s settlement, Denezhkin Kamen, etc. It was a tradition of local residents to just go to the forest to rest, or to pick berries, to “eat” (as the locals said) …

Gulya Gaifieva at a reception with the Minister of Natural Resources of the Sverdlovsk Region Alexei Kuznetsov. Photo from LiveJournal by Vadim Averyanov

Since childhood, I dreamed of becoming a teacher.As a full-time student, we, students, were sent to work in country pioneer camps for teaching practice in the city of Serov (Veterok, Iskorka), in the city of Severouralsk (p / l named after V. Dubinin) for the whole summer. Working in a pioneer camp in the village. Bayanovka spent the night with a detachment to Mount Kumba. While working at school, I went with the class on excursions along well-known routes, at the request of children and their parents. Collective hikes, excursions for children and adults broaden their horizons, they deliberately approach the world around them with love.Such events build fortitude, patience, perseverance, teamwork, friendship and camaraderie.

In 2011, I improved my qualifications at the Sochi State University of Tourism and Resort Business under the program “Excursion activities” and completed the final work on the topic: “Excursion activities”. And in 2020 in the city of Severouralsk with like-minded people they organized a public movement “Our Mountains”.

The Urals are rich in various natural objects and I have a continuation of my dream: to show the beauty of our region to the whole world, to inspire people.The team of our movement is strong enough. People who are interested in the development of the region have gathered here, and we are ready and will do this work, we are all enthusiasts, and I am sure our work will be visible. In this regard, I come up with a proposal to officially open the territory “Denezhkin Kamen” for visitors, transforming its status into a National Park. Taking into account the interests of the public. “, – said Averyanov.

The public figure also published a scan of Ms. Gaifieva’s letter, with a note from Minister Kuznetsov of receipt.

Scan of the letter from Guli Gaifieva (Severouralsk) with the note of the Minister of Natural Resources of the Sverdlovsk Region on receipt. Photo from Vadim Averyanov’s Live Journal

“The Minister thanked the social activist for her active life position and promised to personally respond to her appeal,” Averyanov shared his observations from the personal reception of Alexei Kuznetsov .

Deputy Chairman of the movement “Our Mountains” Gulya Gaifieva (Severouralsk) asks the Minister to transform the reserve “Denezhkin Stone” into a National Park

RG correspondent has found the grave of film actress Guli Koroleva – Rossiyskaya Gazeta

This year marks the 40th anniversary of the release of Igor Voznesensky’s film “The Fourth Height”, an adaptation of the book of the same name by Elena Ilyina.Once upon a time this film was watched, and millions of Soviet schoolchildren were reading the book. Today, not every child will say who Gulya Koroleva is.

Nelly, Gulya, Vasilinka

The great English humorist Charles Dickens has a character named Pip in Great Expectations. That is, in fact, his name was Philip Pirrip, but when trying to pronounce his full name, the boy could only pronounce “Pip”.

Guli has a similar story. At birth, she received an unbearably beautiful, absolutely non-Soviet name Marionella.But due to the fact that the baby was constantly trying to tell something to adults in her Lal language, she was increasingly called not only Nelly, but also Gulya. From the word “walk”. The girl transferred her home nickname to school, and then to the screen.

The filmography of the Queen is small: episodes in the silent “Kashtanka” and “Babakh of Ryazansky”, more prominent roles in the sound films “Sunny Masquerade”, “I Love” and “The Partisan’s Daughter”. Varka and Vasilinka of the latter two made her popular throughout the Union. They wrote letters to Gulet from all over the vast country.Unfortunately, today not all of these films are freely available. Therefore, for most of our contemporaries, the star of black and white cinema, Gulya Koroleva, is known at best as the heroine of works already devoted directly to herself.

During the war, about 45 thousand artists went to the front. As part of propaganda teams, they raised the morale of the soldiers. Perhaps Marionella would have remained a forgotten actress. But she went to the army not to sing and dance, she became a medical instructor. And it raised not only the spirit, but also the wounded soldiers on the battlefield.

Close to dogs

In publications about Gula, it is more often reported about her feat, for which she received the Order of the Red Banner: on November 23, 1942, the girl carried 50 wounded soldiers from the battlefield, and after the death of the commander, she led the attack and with the help of grenades destroyed 15 German soldiers and officers. But the months leading up to this battle in which the Queen was mortally wounded are usually bypassed.

So, what were the everyday life of Guli and her front-line friends?

– Medical instructors were dressed in regular military uniforms, sometimes with an armband with a red cross on the left shoulder.They had accelerated training courses in a couple of hours, they learned only dressing, – says Valentina Chenigina, chief curator of the funds of the Museum of the History of Public Health of the Volgograd Region. – Bandages and cotton wool were put in a canvas sanitary bag. If a tough battle was coming, they tried to put more dressing materials. The bag is quite roomy – it could fit up to four kilograms.

Tracking dogs, mainly shepherds, were used in hard-to-reach places. They also had a sanitary bag on their side with an individual package.If the wounded man retained the ability to move, then he independently provided assistance to himself. When there was not enough strength for this, for such cases the dog had a whistle on a long cord, almost touching the ground, into which a soldier could blow. The whistle is heard much further than a cry for help.

– The dogs were trained so that they did not go near the German soldiers. They identified ours by smell, – adds Chenigina. In response to my silent question, she explains: – From the Soviet fighters it smelled of cigarettes, and the Germans used Nivea skin cream.

3800 steps

It is difficult for us to understand many actions of the heroes of the Great Patriotic War. Why did Zoya Kosmodemyanskaya set fire to peasant huts? Why did Alexander Matrosov rush to the machine gun with his chest? How could Gulya leave her newborn son and go to the front? But their contemporaries did not have such questions. Time itself provided the answers. That is why they survived.

Guli’s character made her constantly challenge fate, take on new barriers. The first height was conquered by the Queen on the set of the film “The Partisan’s Daughter”, when the girl had to overcome fear and perform a difficult trick on horseback.The second is the struggle with her own laziness, when the schoolgirl had to catch up with her classmates in many subjects. The third height took the form of a ten-meter tower, from which Gulya jumped at the competition. The fourth, final, height was even higher, 56.8 meters. This is how the hill for which the battles were fought was indicated on the maps.

There is a little confusion with Guli’s grave. Probably, it could not be otherwise with a man whose biography has long been overgrown with legends. Different official documents indicate two places of burial of Junior Sergeant Marionella Vladimirovna Koroleva: a mass grave in the village of Kotluban and an individual grave in the Sakarka farm.Which option is correct?

– Tell me where Gulya Korolyova is actually buried, – I explain the problem in the Battle of Stalingrad Museum-Reserve.

– In the Ilovlinsky region, in Sakarka, they answer without hesitation.

Yes, and Ilyina’s book says so: “On the banks of the Don, near the Panshino farm (the author has no soft sign -” RG “), the 780th rifle regiment buried its heroes – Gulya Korolev and Alexei Toplin.” So all the readings agree.

A bus runs twice a day to the Panshino farm, on the outskirts of which Gulya died.A local resident assures me that without a guide I will not find the monument “The Fourth Height”, erected on the very hill where the heroine’s life ended.

However, beyond the forest belt, in the steppe, I find an obelisk. The app on the phone shows that I walked only 3800 steps from the stop. It is absolutely deserted here. The monument is in good condition. New trees were planted around it last autumn. Not all have hibernated. Only five out of 47 seedlings hatched buds. Quite Stalingrad arithmetic – one in nine survived.Now the way to Sakarka. Trams do not run here, so I walk to the neighboring farm. On the way, I got into a conversation with the shepherd Alexei:

– We remember about Gulya only on May 9th. And so nobody is interested in anything. Last year I mowed hay in front of the Fourth Height. Some old woman came there. It turned out to be from these places. There was a farm called Verkhniy Gniloy – the Germans burned it down in 15 minutes.

– Have you read The Fourth Height yourself?

– Several times, – Alexey nodded.

Koroleva’s grave is located on the street, which is called the same as our newspaper – Rossiyskaya. Nameplate with surname, name, patronymic. And in brackets – Gulya. The headstone has a wreath with plastic flowers. But next to them the tulips have already raised their heads – they are alive.

Still, the heroes of our story must return to us. “This is not necessary for the dead, it is necessary for the living.” And I hope that the book about Gulya Koroleva will return to the circle of family reading. And every student will know her name. Winning some of the children’s attention from Spider-Man and Harry Potter is not an easy task.The fifth height of Guli.

Guli’s letter to her father

Daddy! You asked me to write to you more often. I sat down to write to you, but I don’t know what to write. Day after day there are fierce battles for the Don, for Stalingrad. We are fighting desperately, our regiment has already received 2 commendations from the Military Council. We are fighting in such a way as to win the guards banner. We work a lot. I’m on the front lines all the time. All the time among the masses. The Red Army men are very warmly greeted. I went on reconnaissance. Been in skirmishes. More than once in the balance of death.But, as they say, the bullet is afraid of the brave. The brave dies once, and the coward several times. How are you doing? Please send me your card. Write to me at: PPS 1682,780th Rifle Regiment, headquarters. Write. I kiss you hard. Gulya. September 10, 1942.

By the way

60 percent of all medical workers were mobilized from the reserve, mostly women. Young doctors, being graduates of accelerated graduates, had no experience. Every second nurse was drafted into the army after 3 to 4 months of Red Cross courses.

There are many real heroines among Guli Koroleva’s colleagues. First-year student Lena Korneva carried about 30 wounded sailors to the crossing, the girl dragged strong men along the ravine of the Tsaritsa River. Medical instructor of the 173rd Infantry Division Masha Taranima carried 100 Soviet soldiers from the battlefield. The exact list of those rescued by Tamara Shmakova is unknown, but there are hundreds of people: Toma knew how to crawl on her bellies under fire. She dragged the wounded either on her back or on a raincoat. Medical instructor Masha Kukharskaya carried 481 soldiers on her.In fact, a whole battalion.

Many wounded people accumulated in Yagodnaya gully near Stalingrad, who could not be evacuated due to shelling. People were taken out on sleds pulled by dogs. Each team could take one recumbent and two able to sit. On the first voyage the dogs were chased by mushers. But the clever animals immediately remembered the road and made the next trips on their own. Another wounded man was put in place of the driver. For two nights, more than 300 soldiers and officers were evacuated from the gully. During the war years, 116 thousand military and 30 thousand civilian doctors in the USSR received state awards.44 health workers became Heroes of the Soviet Union. Among them, 17 are women.

The monument “The Fourth Height” stands at the site of Guli’s death, near the Panshino farm. Photo: Roman Merzlyakov / RG

Tokyo Ghoul (TV series, 4 seasons) – reviews and reviews – Kinopoisk

WarVoid – Tokyo Ghoul Lyrics

My name is Ken Kaneki
An ordinary nerd, and with no one
I cannot be confused, I wrap myself
In my microcosm
I am a letter-reader, and no
I am not at all interesting for others
I geek of books, I have penetrated into them
They teach: “Join the good”

Friend… I have one, Hide
But he didn’t let down
I didn’t make friends for the look
I wanted to go along the path
A quiet life, in a calm backwater
I’m not a knight and not a samurai
But the war machine, they say, start it
The world said, it’s time to die

And then suddenly “One!”
I walked on thin ice
And the crust crunched so I’ll drown …
Swim out of the abyss of death
On other people’s fins
But in the mirror you can clearly see
That something is wrong with me

Changes in the body
Irreversible in bulk
I am here now in subjection
Have bloody instincts
And all away!
My brain is not averse to
To drink blood and taste flesh
Though it tears my heart to shreds
However, I would like to help very much

And people and ghouls
But I don’t know if I can…
Lives go out so often
We are fighting senselessly
Kill, eat, take away
This is a fundamentally wrong world
And I was empowered
So that I can change it!

Hunger will pull me out to the alleys of Tokyo
The city is paved with lonely corpses at night
Take your feet in your hands before they were taken by ghouls here
Not many survive here, don’t stir up a beehive!
Disassembled into pieces nothing will be lost
The food chain has been assured by nature
People are now food evolution as always
Strong individuals feed their fill
Weak.But here …

I wanted to, I didn’t want to, but I got in
In general, I didn’t know about them
But they accepted me here, a hybrid
I want to keep
Both species, half ghoul and human
No one needs war
But head intolerance
Do you want to save those who are dear?
Kill the rest then
In order not to plunge into the darkness
It is better to suffer for others

I thought so, until I had
60 pieces of iron to my hands, feet
Brought and nailed
Nails turned black, obviously
This is all over the edge
Until the weak things to the gods no
In this case, I myself will protect them
! And in my hand the stones
I typed so that completely

Vile creatures and scum – all
They should ask one question:
A thousand minus seven?

In the body of changes
Irreversible in bulk
I am here now in subjection
I have bloody instincts
And all away!
My brain is not averse to
To drink blood and taste flesh
Though it tears my heart to shreds
However, I would like to help very much

And people and ghouls
But I don’t know if I can…
Lives go out so often
We are fighting senselessly
Kill, eat, take away
This is a fundamentally wrong world
And I was empowered
So that I can change it!

Breast cancer in men – Poster Daily

It is generally accepted that breast cancer is a “female” disease, although in fact men are also susceptible to it. In the month of the fight against breast cancer, which takes place every October, “Afisha Daily” tells the story of Alexander, who is being treated for this disease right now.

Alexander, 34 years old

Being treated for stage 4 breast cancer

“I felt the tumor myself”

Six years ago I worked on construction sites, making concrete floors. I often asked for business trips, but I hardly spent time with my family – all the time I wanted to get out somewhere, to see a new city, new people. In the stream of life, time passed very imperceptibly. And suddenly I found out that I have cancer.Then we lived in the town of Horlivka, two hours’ drive from Donetsk.

I felt the tumor myself – I noticed a lump on the nipple. In general, I am suspicious, but it was that time that I did not go to the doctor, I dismissed it – probably out of fear. My father had thyroid cancer, my aunt had breast cancer, and my grandfather had a bladder cancer. Of these, only the father was cured.

Of course, I told my wife about my fears, but she did not particularly push me to turn to doctors. But my mother, as I found out, at every conversation asked me to go to the clinic.As a result, I went to the oncologist a month later, when my chest began to ache. I was already sure it was cancer. I went with my mom.

“I began to reflect on the topic of why I have a female disease”

When we arrived at the hospital, I immediately wanted to leave – I felt some kind of disregard. This is understandable, the war has already begun. There were many problems in the hospital, even in a small one, without me.

Still, the diagnosis was confirmed. The doctor was so calm that at first I didn’t really believe him.The first operation was done somehow unexpectedly easily – after a couple of days I came to the appointment, they gave me a local anesthesia, cut off the nipple right in front of my eyes, and after half an hour they let me go. Before the operation, I did not talk to anyone about the problem, not even my wife. But after the operation, of course, I had to discuss the situation, because I was sent to another hospital, to Donetsk.

In the big city they treated me better, more attentively. Then I began to reflect in almost every office on the topic of why I have a female disease.It was somehow strange and even a little embarrassing. I thought it couldn’t be that way.

When I was prescribed a second operation, more serious, it somehow didn’t give a damn whether a woman’s illness or not — it is cancer.

Until now, no one knows about my illness, except my family and a couple of friends. In principle, I don’t want to talk about cancer. So even if I go to the sauna or pool, I try not to take off my T-shirt so that no one can see the cut off nipple.Men, by the way, if they notice, don’t ask too much questions. But women can get scared.

When I had a general operation, “chemotherapy” and removed the lymph nodes, the war broke out in Donetsk. At that time, one of my daughter was five years old, the second was a year old. It was not up to myself. It was necessary to move urgently.

Topic details

“I Feel Immortal”: How It Is To Beat Breast Cancer

“I Feel Immortal”: How It Is To Beat Breast Cancer

“For two years in a row I said that I had no opportunity to go to an oncologist”

Together with the family of my older sister (she has a husband and a daughter), we moved to St. Petersburg.Since there was not enough money, we had to live in a “kopeck piece” on the outskirts in every possible way. I started to get depressed, I didn’t want to return home: I filled myself up with work, usually at construction sites, and on my free evenings I bought alcohol, sat up with my friends. I had a clear feeling that I had nowhere to come to rest, that I had no place anywhere.

For two years in a row, I said that I had no opportunity to go to an oncologist and get tested. The first six months there was no policy, problems with work and housing continued.And only when my family and I finally moved to a separate apartment, I decided to go to the hospital. All this time, the disease progressed, and I was immediately prescribed a new “chemotherapy”. The treatment was completely free.

I think chemistry is the hardest part of cancer treatment . Constantly nauseous, do not want to eat and sleep, work too. I had nowhere to draw positive emotions. So that life did not seem so unbearable, I had to somehow amuse myself, and I could not think of anything better how to start smoking weed every day – it lasted six months.The mood did not really rise, but the nausea still went away. There was even a desire to work, but it ended badly – with a cough. Then I started making alcohol for friends myself – sambuca, moonshine, whiskey, absinthe. I myself did not drink much, it was a hobby: people came, I sold to someone, gave to someone. This brightened up life a little, albeit not for long. Six months later, the doctor said that the disease began to progress again, and I had liver problems.

When I was diagnosed with breast cancer, I did not seek support and did not really think about the disease, because you walk around and do not notice it.But when problems with my lungs and liver appeared, I began to think about life almost every day, as soon as I got out of bed. During my illness, I became more introverted, fell in love with observing nature, and began to conduct dialogues with myself.

I began by looking for an answer to the question why I was given life at all. Now I think the meaning of life is in the process. Every day becomes a great value for me.

“I often feel lonely”

Usually all cancer patients are offered psychological help.I never went to classes in groups, I also did not receive individual consultations. I don’t want to talk to anyone on this topic at all. Even my wife talks to my doctors, and I try not to get into it.

Sometimes people with such diagnoses turn to faith, but I think this is complete nonsense. I am not an atheist, I believe that God exists, but I don’t want to feed the priests with money. I don’t think there is anything sincere in the church now, and I don’t need these pictures to calm me down.

What I really want now is a warmer relationship with my wife.But it would be foolish to think that only because of illness we will become closer. I often feel lonely. Probably, this is the case for all people, but due to illness, this feeling is sometimes exacerbated. A couple of times I jokingly asked my wife what she would do if I was gone. She doesn’t say anything, just waves it off.

In recent years, I’ve got a wish list. It is a pity that I have never been abroad, and in general I have traveled a little. It seems that in life there were somehow not enough impressions.

But now I cannot allow myself to think about it too often: we still have a difficult situation, I work as a foundry worker, my wife works in a bag factory. The eldest daughter is already 10 years old, and the youngest is six. The youngest daughter did not have enough space in the kindergarten, so the mother-in-law moved to us to sit with her – we also have to take care of the mother-in-law. Also, we still haven’t been issued passports. Money is sorely lacking. If possible, I take a part-time job and work seven days a week.

The hardest thing is to live without a goal. is impossible without a goal. And I can’t make big plans for the future – well, for a year or two it’s still possible. Further – the unknown. Of course, I would like to buy a land plot outside the city, build a house. This is my main task now. You cannot leave a family without a home.

Now I try to spend all my free time with girls. It seems to me that my daughters understand me better than anyone else. With them I am most interested. It’s a pity that I can’t see them more often because of my work. The eldest, at the age of ten, has read more books than his wife in her entire life – it is very easy for me to communicate with the eldest, there is always something to talk about.And the soul becomes very calm. The girls, of course, don’t know what’s wrong with me. I haven’t talked to them yet, I haven’t explained anything. Maybe my wife was saying something … I don’t know. I really feel sorry for the girls.

Topic details

“I know what I can go through”: what it is like to get cancer when you are an oncologist surgeon

“I know what I can go through”: what it is like to get cancer when you are an oncologist surgeon

Ineza Sharvashidze

Chemotherapist of the City Clinical Oncological Dispensary

How is breast cancer (BC) treated? And does the treatment differ between men and women?

Treatment includes three components: surgical, radiation, and medicinal.Oncological treatment is selected individually, taking into account a huge number of parameters. There are no general schemes. At the same time, there is no gender difference in the treatment and structure of breast cancer. Although among men, up to 5% become patients, but among women this type of cancer is in first place in terms of frequency of occurrence. Why is not yet known exactly.

Is it difficult to get psychological help?

In St. Petersburg, free psychological assistance at an oncological dispensary is easily accessible to both patients and relatives.If you wish, you can go through a whole program to restore psychological health. And the sooner the patient takes advantage of this opportunity, the more he will increase the success of treatment in general.

Is psychological support for breast cancer different by gender?

Of course, in men it is not visible that the mammary gland is removed, but this does not mean that they survive the disease easier. Any oncological patient’s worldview turns one hundred and eighty degrees. People become selfish, psychologically vulnerable – regardless of gender .They begin to delve into themselves, thinking what they did wrong. And here the main thing is to help a person stop feeling sorry for himself, stop avoiding contact. He needs to be given faith in his recovery. Never cry in front of him, never walk with a sad face. Science hasn’t explained it yet, but joy and trust can help fight cancer. The mindset is the main remedy. And if there is a purpose in life, then a person lives.

Topic details

A loved one fell ill with cancer: how to support him? 5 tips oncopsychologist

A loved one fell ill with cancer: how to support him? 5 tips from an oncological psychologist

What are the chances of recovering from advanced breast cancer?

Early detection of cancer is paramount.This factor, with further proper treatment, gives excellent chances for a long life. But in our country, quite often, the ailment is detected at stages 3-4. Of course, you should never lower your wings, and with the later stages you can live long enough. As a matter of fact, the main achievements of oncology now relate precisely to the increase in life expectancy precisely at the later stages. But early and late detection are not comparable.

What operations are performed for breast cancer?

If the disease is detected at an early stage, only a sectoral resection with preservation of the organ may be required.Sometimes even without chemotherapy. That is, we can talk about a complete cure and the highest quality of future life. To do this, it is necessary to check every six months or at least once a year. Minimum program – abdominal ultrasound, breast mammogram and lung X-ray. As for breast cancer, it does not appear suddenly, it is difficult not to notice it, the tumor grows slowly. But people still don’t go to the doctor out of fear.

What are the chances of being cured of breast cancer?

Oncodiagnosis is no longer perceived as an unambiguous sentence of fate.