How do gallstones form in the body. What are the main symptoms of gallstones. What causes gallstones to develop. Who is at higher risk for developing gallstones. What are the most effective treatment options for gallstones. How can gallstone attacks be prevented. What diet changes may help after gallbladder removal.

What Are Gallstones and How Do They Form?

Gallstones are solid, pebble-like deposits that form in the gallbladder. They develop when substances in bile, such as cholesterol or bilirubin, become too concentrated and crystallize. The gallbladder is a small organ located under the liver that stores and concentrates bile, which helps digest fats in the small intestine.

There are two main types of gallstones:

• Cholesterol stones – Made primarily of hardened cholesterol, these account for about 80% of gallstones
• Pigment stones – Composed mainly of bilirubin, these are less common

Gallstones can range in size from tiny grains of sand to golf balls. They may be single or multiple. The formation of gallstones is a gradual process that can take years.

Why do gallstones form?

Gallstones may develop if:

• Bile contains too much cholesterol
• Bile contains too much bilirubin
• The gallbladder doesn’t empty completely or frequently enough
• There are not enough bile salts in the bile

The exact reasons why these changes in bile composition occur are not fully understood. However, certain risk factors make some people more prone to developing gallstones.

Common Symptoms and Complications of Gallstones

Many people with gallstones have no symptoms and are unaware they have them. These are known as “silent” gallstones and typically don’t require treatment. However, when gallstones cause blockages, they can lead to sudden, intense pain called a gallbladder attack or biliary colic.

What are the symptoms of a gallbladder attack?

Common symptoms of a gallbladder attack include:

• Sudden, intense pain in the upper right abdomen
• Pain that may spread to the back or right shoulder blade
• Nausea or vomiting
• Pain lasting several hours
• Pain that often occurs after heavy meals, especially in the evening or at night

If gallstones block bile ducts for more than a few hours, more severe complications can develop. These may include inflammation of the gallbladder (cholecystitis), liver (hepatitis), or pancreas (pancreatitis).

When should you seek immediate medical care for gallstones?

See a doctor right away if you experience:

• Abdominal pain lasting more than 5 hours
• Fever or chills
• Yellowing of the skin or whites of the eyes (jaundice)
• Tea-colored urine and light-colored stools

These symptoms may indicate a serious infection or blockage that requires prompt medical attention.

Risk Factors for Developing Gallstones

While the exact causes of gallstone formation are not fully understood, certain factors increase the risk:

Who is more likely to develop gallstones?

• Women (especially those who are pregnant, take birth control pills, or use hormone replacement therapy)
• People over 40 years old
• Those with a family history of gallstones
• Native Americans and Mexican Americans
• Overweight or obese individuals
• People who lose weight very quickly
• Those with diabetes
• People with liver disease
• Those on cholesterol-lowering medications

Understanding these risk factors can help individuals take steps to reduce their likelihood of developing gallstones.

Diagnosis and Medical Treatment Options for Gallstones

If gallstones are suspected, doctors typically use imaging tests to confirm the diagnosis. These may include ultrasound, CT scans, or MRI scans. Blood tests may also be done to check for signs of infection or blockage.

What are the main treatment options for symptomatic gallstones?

1. Cholecystectomy (surgical removal of the gallbladder) – This is the most common and effective treatment, often done laparoscopically
2. Ursodeoxycholic acid (Ursodiol) – Oral medication that can dissolve small cholesterol stones over time
3. Lithotripsy – Uses shock waves to break up stones, but is only suitable for certain types of stones

For silent gallstones that don’t cause symptoms, watchful waiting is often recommended. Regular check-ups can monitor for any changes or development of symptoms.

Lifestyle Changes and Prevention Strategies

While not all gallstones can be prevented, certain lifestyle changes may help reduce the risk of developing them or experiencing complications.

How can you lower your risk of gallstones?

• Maintain a healthy weight
• Avoid rapid weight loss or yo-yo dieting
• Exercise regularly
• Eat a balanced diet rich in fiber and healthy fats
• Limit foods high in cholesterol and saturated fats
• Stay hydrated

For those who have had their gallbladder removed, dietary modifications may be necessary to manage digestion. This often involves eating smaller, more frequent meals and limiting fatty foods.

The Myth of Gallbladder Cleanses

Some alternative health practitioners promote “gallbladder cleanses” or “liver flushes” as natural remedies for gallstones. These typically involve consuming large amounts of olive oil and fruit juice over several hours.

Do gallbladder cleanses work?

There is no reliable scientific evidence that gallbladder cleanses are effective in treating or preventing gallstones. What people often mistake for passed gallstones after a cleanse are actually soap-like balls formed by the olive oil and juice mixture.

These cleanses can be risky, potentially causing:

• Nausea and vomiting
• Diarrhea
• Abdominal pain
• Dehydration

It’s important to consult with a healthcare professional before trying any alternative treatments for gallstones.

Living Without a Gallbladder: Adjustments and Considerations

For many people with problematic gallstones, cholecystectomy (surgical removal of the gallbladder) is the recommended treatment. While the gallbladder serves a purpose, it’s not essential for survival, and most people adjust well to life without one.

What changes might you experience after gallbladder removal?

After gallbladder removal, bile flows directly from the liver into the small intestine. This can lead to some changes in digestion, including:

• Looser, more frequent stools
• Difficulty digesting fatty foods
• Temporary diarrhea (usually resolves within a few weeks)

Most people can return to a normal diet within a few weeks, but some may need to make long-term dietary adjustments.

How can you manage your diet after gallbladder removal?

To aid digestion and minimize discomfort after gallbladder surgery, consider these dietary tips:

• Eat smaller, more frequent meals
• Gradually reintroduce fatty foods
• Increase fiber intake to help normalize bowel movements
• Stay hydrated
• Consider taking a bile salt supplement if recommended by your doctor

While these changes can help, it’s important to work with your healthcare provider to develop a personalized plan that meets your nutritional needs.

Ongoing Research and Future Directions in Gallstone Treatment

While current treatments for gallstones are generally effective, researchers continue to explore new approaches to prevention and treatment.

What new treatments for gallstones are being researched?

Some areas of ongoing research include:

• Improved medications to dissolve gallstones
• Non-invasive techniques to break up gallstones
• Gene therapies to prevent gallstone formation
• Probiotics to influence bile composition

Additionally, scientists are working to better understand the genetic and environmental factors that contribute to gallstone formation. This could lead to more targeted prevention strategies in the future.

As our understanding of gallstone formation and its risk factors continues to grow, we may see new recommendations for prevention and early intervention. For now, maintaining a healthy lifestyle and being aware of gallstone symptoms remain the best approaches for most people.

Gallbladder cleanse: A ‘natural’ remedy for gallstones?

What is a gallbladder cleanse? Is it an effective way to flush out gallstones?

Answer From Brent A. Bauer, M.D.

A gallbladder cleanse — also called a gallbladder flush or a liver flush — is an alternative remedy for ridding the body of gallstones. However, there’s no reliable evidence that a gallbladder cleanse is useful in preventing or treating gallstones or any other disease.

In most cases, a gallbladder cleanse involves eating or drinking a combination of olive oil, herbs and some type of fruit juice over several hours. Proponents claim that gallbladder cleansing helps break up gallstones and stimulates the gallbladder to release them in stool.

Although olive oil can act as a laxative, there’s no evidence that it’s an effective treatment for gallstones. Also, people who try gallbladder cleansing might see what looks like gallstones in their stool the next day. But they’re really seeing globs of oil, juice and other materials.

Gallbladder cleansing is not without risk. Some people have nausea, vomiting, diarrhea and abdominal pain during the flushing or cleansing period. The ingredients used in a gallbladder cleanse can present their own health hazards.

Gallstones that cause no symptoms typically require no treatment. If you have gallstones that require treatment, discuss proven treatment options with your doctor, such as surgical removal, bile salt tablets or sound wave therapy.

• Can you recommend a diet after gallbladder removal?

April 03, 2020

Show references

1. Rakel D, ed. Cholelithiasis. In: Integrative Medicine. 4th ed. Elsevier; 2018. https://www.clinicalkey.com. Accessed Feb. 10, 2020.
2. “Detoxes” and “cleanses”: What you need to know. National Center for Complementary and Integrative Health. https://nccih.nih.gov/health/detoxes-cleanses. Accessed Feb. 10, 2020.
3. Treatment of gallstones. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/digestive-diseases/gallstones/treatment. Accessed Feb. 10, 2020.

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Symptoms & Causes of Gallstones

What are the symptoms of gallstones?

If gallstones block your bile ducts, bile could build up in your gallbladder, causing a gallbladder attack, sometimes called biliary colic. Gallbladder attacks usually cause pain in your upper right abdomen, sometimes lasting several hours. Gallbladder attacks often follow heavy meals and usually occur in the evening or during the night. If you’ve had one gallbladder attack, more attacks will likely follow.

Gallbladder attacks usually stop when gallstones move and no longer block the bile ducts. However, if any of your bile ducts stay blocked for more than a few hours, you may develop gallstone complications. Gallstones that do not block your bile ducts do not cause symptoms.

When you develop gallstones that block your bile ducts, bile builds up in your gallbladder, causing a gallbladder attack.

Silent gallstones

Most people with gallstones do not have symptoms. Gallstones that do not cause symptoms are called silent gallstones. Silent gallstones don’t stop your gallbladder, liver, or pancreas from working, so they do not need treatment.

Seek care right away for a gallbladder attack

See a doctor right away if you are having these symptoms during or after a gallbladder attack:

• pain in your abdomen lasting several hours
• nausea and vomiting
• fever—even a low-grade fever—or chills
• yellowish color of your skin or whites of your eyes, called jaundice
• tea-colored urine and light-colored stools

These symptoms may be signs of a serious infection or inflammation of the gallbladder, liver, or pancreas. Gallstone symptoms may be similar to symptoms of other conditions, such as appendicitis, ulcers, pancreatitis, and gastroesophageal reflux disease, all of which should be treated by a doctor as soon as possible.

Gallstone complications can occur if your bile ducts stay blocked. Left untreated, blockages of the bile ducts or pancreatic duct can be fatal.

What causes gallstones?

Gallstones may form if bile contains too much cholesterol, too much bilirubin, or not enough bile salts. Researchers do not fully understand why these changes in bile occur. Gallstones also may form if the gallbladder does not empty completely or often enough. Certain people are more likely to have gallstones than others because of their risk factors for gallstones, including obesity and certain kinds of dieting.

Picture, Symptoms, Types, Causes, Risks, Treatments

What Are Gallstones?

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

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

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

Gallstone Types

The two main kinds of gallstones are:

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

Signs and Symptoms of Gallstones

Symptoms may include:

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

Causes of Gallstones

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

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

Gallstone Risk Factors

You’re more likely to get gallstones if you:

Gallstone Diagnosis

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

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

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

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

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

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

Endoscopic retrograde cholangiopancreatography (ERCP). Your doctor runs a tube called an endoscope through your mouth down to your small intestine. They inject a dye so they can see your bile ducts on a camera in the endoscope. They can often take out any gallstones that have moved into the ducts.

Endoscopic ultrasound. This test combines ultrasound and endoscopy to look for gallstones.

Gallstone Treatment

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

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

Laparoscopic cholecystectomy. This is the most common surgery for gallstones. Your doctor passes a narrow tube called a laparoscope into your belly through a small cut. It holds instruments, a light, and a camera. They take out your gallbladder through another small cut. You’ll usually go home the same day.

Open cholecystectomy. Your doctor makes bigger cuts in your belly to remove your gallbladder. You’ll stay in the hospital for a few days afterward.

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

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

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

Complications of Gallstones

Gallstones can cause serious problems, including:

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

Preventing Gallstones

Some lifestyle changes might lower your risk of gallstones.

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

Gallstones Picture, Causes, Age, & Symptoms

Gallstones are crystal-like deposits that develop in the gallbladder — a small, pear-shaped organ that stores bile, a digestive fluid produced by the liver.

These deposits may be as small as a grain of sand or as large as a golf ball; they may be hard or soft, smooth or jagged. You may have several gallstones or just one.

Some 30 million American adults suffer from gallstones. Yet most of those who have the condition do not realize it. In this case, what you don’t know probably won’t hurt you; gallstones that are simply floating around inside the gallbladder generally cause no symptoms and no harm.

These “silent” stones usually go unnoticed unless they show up in an ultrasound exam conducted for some other reason. However, the longer a stone exists in the gallbladder, the more likely it is to become problematic. People who have gallstones without symptoms have 20% chance of having an episode of pain during their lifetime.

When symptoms do occur, it’s usually because the gallstone has moved and become lodged within a duct that carries bile, such as the cystic duct, a small conduit that connects the gallbladder to another tube called the common bile duct. The typical symptom is abdominal pain, perhaps accompanied by nausea, indigestion, or fever. The pain, caused by the gallbladder’s contraction against the lodged stone, generally occurs within an hour of eating a large meal or in the middle of the night. Stones can also clog the common bile duct, which carries bile into the small intestine, and the hepatic ducts, which take bile out of the liver.

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Obstructions in the bile pathway may cause a duct to become inflamed and possibly infected. Blockage of the common bile duct, which merges with the pancreatic duct at the small intestine, can also lead to inflammation of the pancreas (gallstone pancreatitis).

In a rare but dangerous condition that occurs most often in older women, gallstones migrate into the small intestine and block the passageway into the large intestine; symptoms include severe and frequent vomiting. Although gallstones are present in about 80% of people with gallbladder cancer, it is uncertain whether gallstones play a role, except when really large stones (greater than 3 centimeters in diameter) are present.

Continued

About a million new cases of gallstones are diagnosed in the U.S. each year. For reasons that are still unclear, women are two times more likely than men to be afflicted. Native Americans have the highest rates of gallstones in the U.S. because they have a genetic disposition to secrete high levels of cholesterol in bile (a contributing factor to gallstones.) Mexican-Americans also have high rates of gallstones.

Gallstones are also more common in people over age 60, in those who are obese or have lost a lot of weight in a short amount of time, in those who have diabetes or sickle cell disease, and in women who have had multiple pregnancies and who take hormone replacement therapy or birth control pills.

What Causes Gallstones?

The primary function of the gallbladder is to store bile, a brown or yellowish fluid that helps the body break down fatty food. When you eat a meal, the gallbladder releases its stored bile into the cystic duct. From there the fluid passes through the common bile duct and into the small intestine to mix with food.

Chief among the ingredients of bile are cholesterol and bile acids. Normally, the concentration of bile acids is high enough to break down the cholesterol in the mixture and keep it in liquid form. However, a diet high in fat can tip this delicate balance, causing the liver to produce more cholesterol than the bile acids are able to handle. As a result, some of this excess cholesterol begins to solidify into crystals, which we call gallstones. About 80% of all gallstones are called cholesterol stones and are created this way. The remaining 20% consist of calcium mixed with the bile pigment bilirubin and are called pigment stones. Sickle cell and other blood disorders where red blood cells are destroyed can often lead to pigment gallstones

Continued

Gallstones can form even in people who eat properly. And as researchers have found, a diet extremely low in fat can also contribute to gallstone formation: With little fatty food to digest, the gallbladder is called into play less frequently than usual, so the cholesterol has more time to solidify. Other factors that can reduce activity in the gallbladder, possibly leading to gallstone formation, include cirrhosis, the use of birth control pills or hormone replacement therapy, and pregnancy.

Family history, diabetes, sudden weight loss, and cholesterol drugs, and older age can also increase risk for gallstones.

Gallstones Diagnosis, Tests, & Treatments

How Do I Know if I Have Gallstones?

If your symptoms suggest a gallstone problem, your doctor might first examine your skin for jaundice, and then feel your abdomen to check for tenderness. A blood test may reveal evidence of an obstruction.

Because other digestive problems, such as an infection of the duct, can produce symptoms similar to those of a gallstone attack, the doctor may also run other tests to determine if gallstones are in fact the culprit.

The most common technique is an ultrasound exam. This quick, painless procedure uses high-frequency sound waves to create pictures of the gallbladder, bile duct, and their contents. CT scans are also sometimes done to look at the anatomy of your internal organs.

A more complicated test may be used if the doctor suspects that a gallstone is lodged in a bile duct. Commonly known by the acronym ERCP, this test allows the doctor to look at the bile duct through a small flexible tube called an endoscope. The doctor sprays the back of the patient’s throat with an anesthetic drug to prevent gagging, sedates the patient, and passes the endoscope into the mouth, through the stomach, and into the area of the small intestine where the bile duct enters. Dye is injected through the tube and into the bile duct, and then the doctor takes X-rays. Stone removal can be done during this procedure as well. The procedure takes about an hour.

What Are the Treatments for Gallstones?

In most cases, treatment of gallstones is considered necessary only if you are having symptoms. Of the various conventional treatments that are available, surgical removal of the gallbladder is the most widely used. Some alternative treatments have also been found to be effective in alleviating the symptoms of troublesome gallstones.

Conventional Medicine for Gallstones

When deciding what course of action to take for symptomatic gallstones, doctors usually choose from among three main treatment options: Watchful waiting, nonsurgical therapy, and surgical removal of the gallbladder.

Gallstones and Watchful Waiting

Though a gallstone episode can be extremely painful or frightening, almost a third to half of all people who experience an attack never have a recurrence. In some cases, the stone dissolves or becomes dislodged and thereby resumes its “silence.” Because the problem may solve itself without intervention, many doctors take a wait-and-see approach following the initial episode.

Even when the patient has had repeated gallstone episodes, the doctor may postpone treatment or surgery because of other health concerns. If your surgery has been delayed, you should remain under a doctor’s care and report any recurrences of gallstone symptoms immediately.

Nonsurgical Therapy for Gallstones

If you are unable or unwilling to go through surgery for a gallstone problem that requires treatment, your doctor may recommend one of several noninvasive techniques. Note that though these methods may destroy symptom-causing gallstones, they can do nothing to prevent others from forming, and recurrence is common.

Some gallstones can be dissolved through the use of a bile salt, although the procedure can be used only with stones formed from cholesterol and not from bile pigments. The drug Actigall (ursodiol) is taken as a tablet; depending on its size, the gallstone may take months or even years to go away. Because some stones are calcified, this treatment often doesn’t work.

Another nonsurgical technique, shock wave therapy, uses high-frequency sound waves to fragment the stones. Bile salt is administered afterward to dissolve small pieces. This therapy is rarely used.

Doctors can also attempt to remove gallstones during an ERCP. During the procedure an instrument is inserted through the endoscope to attempt removal of the stone.

While these therapies may work for some, all of the above nonsurgical therapies are usually unsuccessful long term (since recurrence is common) and are rarely advised in clinical practice.

Surgery to Remove the Gallbladder

While the gallbladder serves an important function, it is not essential for a normal, healthy life. When gallstones are persistently troublesome, doctors often recommend removing the organ entirely. This operation is considered among the safest of all surgical procedures. Each year approximately 750,000 Americans have their gallbladder removed. It is also the only treatment method that eliminates the possibility that other gallstones will develop in the future.

When the gallbladder has been removed, bile flows directly from the liver into the small intestine, and this sometimes leads to diarrhea. Because bile no longer accumulates in the gallbladder, quantities of the digestive fluid cannot be stored up and used to break down an especially fatty meal. This condition is not considered serious, however, and can be corrected by simply limiting fat in the diet.

In the past, removal of the gallbladder was done through traditional “open” surgery, which requires surgeons to make a large incision in the abdomen. Patients faced a two- or three-day hospital stay plus several weeks of recovery at home.

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Today, however, the most commonly used surgical technique is a much simpler approach known as laparoscopic cholecystectomy. The doctor makes several small incisions in the abdomen, then uses special pencil-thin instruments to remove the gallbladder. A tiny microscope and video camera, snaked through the incision to the site, allow the surgeon to view the operation.

Laparoscopic surgery is highly effective and very safe. It has reduced the hospital stay to a day or two. Patients report less pain and are generally able to resume a normal lifestyle in a short period of time. However, people who are obese or who have a severe infection or inflammation in the gallbladder may still be considered candidates for traditional open surgery.

Gallbladder Surgery & Removal for Gallstones: What to Expect

Your gallbladder is a pear-shaped organ that stores bile, the fluid that helps digest food. If it’s not working the way it should (or your bile gets out of balance), hard fragments start to form. These can be as small as a grain of rice or as big as a golf ball.

Gallstones don’t go away on their own. If they start to hurt or cause other symptoms, your doctor may decide to remove your gallbladder. This type of surgery is called a cholecystectomy. It’s one of the most common surgeries doctors perform.

About 80% of people who have gallstones will need surgery.

Types of Gallbladder Surgery

Doctors can remove your gallbladder in one of two ways:

Open surgery: During this procedure, your surgeon will make a 5- to 7-inch incision (cut) on your belly to take out your gallbladder. You’ll need open surgery if you have a bleeding disorder. You may also need it if you have severe gallbladder disease, are very overweight, or are in your last trimester of pregnancy.

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Laparoscopic cholecystectomy: Doctors also call this “keyhole surgery.” Your surgeon doesn’t make a big opening in your belly. Instead, they make four small cuts. They insert a very thin, flexible tube that contains a light and a tiny video camera into your belly. These help your surgeon see your gallbladder better. Next, they’ll insert special tools to remove the diseased organ.

For both types of surgery, you’ll be given general anesthesia. This means you’ll sleep through the procedure and won’t feel any pain while it’s being done.

Do I Need Surgery?

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

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

Continued

If left untreated, gallstones can also lead to more serious problems, like:

• Cholecystitis — an inflamed gallbladder
• Pancreatitis — an inflamed pancreas
• Cholangitis — inflamed bile ducts

Before your doctor opts for surgery, they’ll run several tests to see the effect your gallstones are having on your health. Tests might include:

• Blood test
• Ultrasound
• MRI HIDA (hepatobiliary iminodiacetic acid) scan — a radioactive chemical is put into your body to create images of any blocked ducts
• Endoscopic ultrasonography — an imaging device is put into your mouth and down through your digestive tract so sound waves can create a detailed picture of your small intestine

Can I Try Other Treatments First?

You may be able to manage your symptoms for a short time by making changes to your diet. This includes cutting back on fatty foods. But dietary changes don’t always help prevent gallbladder attacks.

If surgery isn’t an option for you, your doctor can prescribe a medication to dissolve your gallstones. But this can take months or even years to work. And even if your gallstones do go away, there’s a chance they’ll return.

Gallbladder Surgery Risks

You can live without your gallbladder. Your liver can make enough bile on its own. This will naturally find its way into your small intestine even if your gallbladder is removed.

Doctors believe gallbladder surgery is safe, but some problems can still arise. These may include:

• Problems with anesthesia
• Infection
• Bleeding
• Swelling
• Bile leakage
• Damage to a bile duct
• Damage to your intestine, bowel, or blood vessels
• Deep vein thrombosis (blood clots)
• Heart problems
• Pneumonia

You also run the risk of a problem doctors call “post-cholecystectomy syndrome” (PCS). It can happen if any gallstones are left in your bile ducts or bile happens to leak into your stomach. The symptoms of PCS are similar to those of gallstones. They include belly pain, heartburn, and diarrhea.

Recovery

The length of time it takes you to heal depends on the type of surgery you have.

If you have your gallbladder removed during open surgery, you’ll need to stay in the hospital for a few days afterward. It may take between 6 to 8 weeks for your body to heal fully.

Laparoscopy is less involved, so you’ll have less pain and heal faster than if you have open surgery. Most people who have it are able to go home from the hospital the same day. You’ll likely be back to your normal routine within 2 weeks.

How do gallstones form?

The human body is known to produce stones in various locations, most commonly in the kidneys, the bladder, the gallbladder and the appendix. Many of these stones appear without any obvious reason. However, a new study published in the journal Immunity shows the whole storyline for the first time: how gallstones are formed.

Gallstones: what are they?

Gallstones are stones that form within the gallbladder, affecting about 25 million Americans and in Germany, about 6 million. In the USA, about 100,000 people die each year of gallstones and associated complications, and this disease is among the top causes for hospitalization.

Gallstone / Gall bladder stone. Image Credit: eleonimages / Shutterstock

Gallstones are typically composed of cholesterol and calcium crystals. The gallbladder epithelium concentrates bile and increases its acidity, so that cholesterol and calcium salts can dissolve in it to saturation levels and beyond. At such a point, supersaturation and precipitation occurs, leading to the crystallization of cholesterol and calcium salts. However, this is not just a physicochemical process. There is also an unknown aggregating agent that causes gallstones to form first, and then grow. The present study throws light on this factor.

The problem with gallstones is that while most are asymptomatic, some cause extreme colic, or waves of spasmodic pain in the abdomen. More serious if not more painful complications may also arise, including perforation of the gallbladder, peritonitis or infection of the general abdominal cavity, and even death. Surgery is the way out in such a case. Most gallstones are cholesterol crystals, and are more frequent in people who have high cholesterol levels. However, how the microscopic crystals of cholesterol build up into stones as large as several centimeters across is a surprisingly under-researched topic – until now.

The search

The current study used a nontraditional approach to their investigation into how gallstones occur – one which took them on a tour of museums, butcher houses and modern operation rooms. They looked at human gallstones kept on display at the Charité hospital museum in Berlin and did their own tests. They examined pig bile from an abattoir. They even analyzed bile and gallstones from patients who had surgical procedures for gallstone disease.

The first step was taken when they successfully analyzed the composition of biliary sludge, the granular concentrated material within gallbladders containing gallstones. The sludge came from patients on hepatobiliary stents. Fluorescence microscopy was carried out on this material, and the researchers found large clumps of extracellular DNA (ecDNA), and high levels of neutrophil elastase activity.

Secondly, they found that ecDNA was also seen in pig biliary sludge, and in human gallstones. Moreover, they found that ecDNA, neutrophil elastase and histone h4 ( a DNA-associated protein) were all found on the surface of gallstones, indicating the role played by NET in the formation of gallstones. Almost 90% of gallstones also showed evidence of neutrophil elastase activity at the surface, the actively growing part, whether or not active inflammation was present. Thus neutrophil deposition of ecDNA is a key event in gallstone formation.

The discovery

Subjecting these varied materials to modern investigative techniques, the team found one common factor: all gallstones are covered with traces of a white cell type called neutrophils, part of the granulocyte population in the blood. These immune cells form part of the first frontier against invading bacteria and other harmful particles, including crystals which are not normally found in the blood.

When they encounter cholesterol crystals in the gallbladder, they go into their usual act, attempting to engulf the crystals and dispose of them. However, in the process they undergo severe damage, with lysosomal disruption. The digestive lysosomal enzyme granular cathepsin G enters the cytoplasm, binds to DNA and causes the strands to spread out like a network, and finally extrudes them from the cell. this lysosomal leakage causes the formation of a sticky network of chromatin strands over the surface of the crystals. This is called a neutrophil extracellular trap (NET). The NET wraps around multiple crystals to form clumps, forming increasingly large stones.

To prove this, the team found that when cholesterol and calcium crystals in solution were added to a neutrophil culture and incubated, small crystals were quickly precipitated, and gallstones began to form and grow. Both calcium and cholesterol crystals are found in gallstones, because of the effect of NET on crystals clustered together by the sticky tide of bile within the gallbladder.

The way out

The researchers also tested the effects of temporarily incapacitating neutrophils in vivo, or of NET inhibitors, and found that both reduced gallstone growth. The striking discovery is that “The production of gallstones can be greatly reduced or even stopped if the formation of these nets is inhibited using drugs,” according to researcher Luis Munoz. Using drugs to treat gallstones in this way is a previously unexplored option.

For instance, the drug Metoprolol could be used in this way. This is a simple beta-blocker, so called because it blocks the beta-adrenergic receptors that mediate some effects of chemicals like adrenaline on various body organs and tissues. This drug has thus been in use for many years to treat high blood pressure. However, when used in patients with gallstones, metoprolol inhibits the entry of neutrophils into the circulation from the tissues. This automatically reduces NET formation and thus brings down the chances of gallstone formation. There are also other drugs called PAD inhibitors, which selectively prevent NET formation from neutrophils in experimental setups. These validate the role ascribed to the immune system in gallstone formation in the current study.

The importance of this process is that it applies not only to gallstone formation but also to kidney and salivary gland stones, among others. This means that these can also be prevented by the same drugs, which will provide relief to many sufferers without the need for surgery.

Journal reference:

Neutrophil extracellular traps initiate gallstone formation. Luis E. Muñoz, Sebastian Boeltz, Rostyslav Bilyy, Christine Schauer, Aparna Mahajan, Navena Widulin, Anika Grüneboom, Irmgard Herrmann, Edgyda Boada, Manfred Rauh, Veit Krenn, Mona H.C. Biermann, Malgorzata J. Podolska, Jonas Hahn, Jasmin Knopf, Christian Maueröder, Solomiya Paryzhak, Tetiana Dumych, Yi Zhao, Markus F. Neurath, Markus H. Hoffmann, Tobias A. Fuchs, Moritz Leppkes, Georg Schett, & Martin Herrmann. August 15, 2019. DOI:https://doi.org/10.1016/j.immuni.2019.07.002. https://www.cell.com/immunity/fulltext/S1074-7613(19)30318-8

90,000 Gallstones – Should I Operate?

28.11.2018

The formation of stones in the gallbladder is the main symptom of cholelithiasis (GSD). In Russia and Europe, this disease is recorded in 10-15% of the population. The source of development of stones is cholesterol, salts and other components of bile, which is formed in the liver and then accumulates in the gallbladder. The formation of gallstones is facilitated by stagnation of bile, inflammation in the wall of the gallbladder and ducts, hormonal and metabolic disorders.Sometimes gallstones may not manifest themselves, but more often they cause pain and other concerns. The greatest danger is posed by complications of gallstone disease.

Why is cholelithiasis dangerous?

– The presence of stones in the gallbladder constantly maintains inflammation in its wall. In the presence of provoking factors – the intake of fatty foods, alcohol, physical activity – the inflammation is exacerbated, and an attack of acute cholecystitis develops, which may require emergency surgery.It is impossible to completely cure chronic cholecystitis in the presence of gallstones.

– The contraction of the gallbladder after a meal can lead to the wedging of a stone into the excretory duct of the bladder, as a result of which the gallbladder becomes clogged and creates a “disabled gallbladder” effect.

– Small stones can slip from the gallbladder into the bile ducts, causing jaundice and acute pancreatitis. These diseases require urgent surgical treatment and to this day often lead to death.

– Large stones can cause a pressure ulcer in the wall of the gallbladder. In this case, a fistula usually develops between the gallbladder and the intestine. The constant reflux of intestinal contents into the gallbladder and bile ducts leads to the development of severe inflammation in them.

– With a prolonged course of calculous cholecystitis, chronic pancreatitis inevitably develops. In this case, even the elimination of cholecystitis (removal of the gallbladder) does not give a complete recovery, since pancreatitis continues to cause pain and other complaints.

– Prolonged trauma to the wall of the gallbladder by stones in it can lead to the development of gallbladder cancer.

Methods for the treatment of gallstone disease?

The main method of treatment of gallstone disease is surgical. The methods of dissolving and crushing gallstones did not justify themselves due to low efficiency, a large number of complications, and high cost of treatment.

For over 100 years, the main operation used for cholecystectomy has been the removal of the gallbladder.It makes no sense to remove stones alone, as the cause of the disease is that the diseased gallbladder forms stones, and not stones cause gallbladder disease.

Previously, the gallbladder was removed through a large incision in the abdominal wall. Now the “gold standard” in the treatment of gallstone disease is laparoscopic cholecystectomy, performed through small punctures. The operation takes about an hour. Postoperative hospital stay – 1-2 days. After surgery, it is recommended to limit excessive physical activity and follow a diet for 1 to 2 months.

Today, laparoscopic cholecystectomy is a fairly safe operation. The complication rate does not exceed 0.1-0.3%, which is lower than with open surgery.

What to do in case of detection of ZhKD?

Don’t expect complications! The first step on the road to recovery is to call us and come for a consultation with a surgeon. A specialist in our multidisciplinary clinic will determine the need for surgical treatment and answer all your questions.

Today, only one list of life-threatening complications of cholelithiasis dictates the need for urgent treatment of this disease. The recommendation “do not remove stones if they don’t bother you” should be recognized as hopelessly outdated.

Find out more about the possibilities of the Center for Minimally Invasive Surgery at the Reaviz multidisciplinary clinic.

90,000 symptoms and when to see a doctor

For diagnostics and treatment of gallstones, read the link.

Get immediate help if you develop signs and symptoms of a serious complication of gallstones, for example:

• Abdominal pain is so severe that you cannot sit still or find a comfortable position
• Yellowing of the skin and whites of the eyes (jaundice)
• High temperature with chills

The number for calling an ambulance in Moscow is 103

Causes of ZhKB

It is not clear what causes gallstones.Doctors believe that gallstones can occur in the following cases:

Your bile contains too much cholesterol . Usually, your bile contains enough chemicals to dissolve the cholesterol secreted by your liver. But if your liver secretes more cholesterol than bile can dissolve, the excess cholesterol can turn into crystals and eventually stones.

Your bile contains too much bilirubin . Bilirubin is a chemical that is produced when red blood cells are broken down in the body.Under certain conditions, the liver produces too much bilirubin, including cirrhosis of the liver, biliary tract infections, and some blood disorders. Excess bilirubin contributes to the formation of gallstones.

Your gallbladder is not emptying properly. If the gallbladder is not emptied completely or frequently enough, bile can become very concentrated, which contributes to the formation of gallstones.

Types of gallstones

Types of gallstones that can form in the gallbladder include:

Cholesterol stones in the gallbladder.The most common type of gallstones, called cholesterol gallstones, are often yellow in color. These gallstones are composed primarily of undissolved cholesterol, but may contain other components as well.

Pigmented stones in the gallbladder. These dark brown or black stones form when your bile contains too much bilirubin.

Risk factors

Factors that can increase your risk of gallstones include:

• Female
• Age 40 and over
• Overweight or obese
• Sedentary
• Pregnancy
• High Fat Diet
• High Cholesterol Diet
• Low Fiber Diet
• Family history of gallstones
• Diabetes
• Presence of certain blood disorders such as sickle cell disease or leukemia
• Very fast weight loss
• Taking medications containing estrogen, such as oral contraceptives or hormone therapy.
• Liver disease

Complications

Complications of gallstones may include:

Inflammation of the gallbladder . A gallstone lodged in the neck of the gallbladder can cause inflammation of the gallbladder (cholecystitis). Cholecystitis can cause severe pain, peritonitis.

Blockage of the common bile duct . Gallstones can block the channels (ducts) that carry bile from the gallbladder or liver into the small intestine.This can lead to severe pain, jaundice, and bile duct infection.

Blockage of the pancreatic duct . The pancreatic duct is a tube that runs from the pancreas and connects to the common bile duct just before entering the duodenum. The pancreatic juices, which aid digestion, pass through the pancreatic duct.

A stone in the gallbladder can cause blockage of the pancreatic duct, which can lead to inflammation of the pancreas (pancreatitis).Pancreatitis causes severe, persistent abdominal pain and usually requires hospitalization. Severe forms of pancreatitis often end in the death of the patient.

Gallbladder cancer . People with gallstones have an increased risk of developing gallbladder cancer.

Prevention of ZhKB

You can reduce your risk of gallstones:

Don’t skip meals . Try to stick to your normal meal times every day.Skipping meals or fasting can increase your risk of gallstones.

Lose weight slowly . If you need to lose weight, take your time. Rapid weight loss can increase your risk of gallstones.

Eat more high-fiber foods . Include more fiber-rich foods such as fruits, vegetables, and whole grains in your diet.

Maintain a healthy weight . Obesity and being overweight increase the risk of gallstone formation.Work towards a healthy weight by reducing your calorie intake and increasing your physical activity. Once you reach a healthy weight, work to maintain it by continuing to eat a healthy diet and exercise.

90,000 Modern view of the causes of gallstones

The gallbladder is a reservoir for the accumulation and thickening of bile, which is a complex liquid, consisting of 85% water.Bile contains organic and inorganic substances: bile acids; cholesterol; bilirubin; phospholipids; immunoglobulins; ions of non-metals; metals and other substances. Gallstones are hardened formations of substances found in bile.

Depending on the substance prevailing in the composition of gallstones, they are divided into two types. The most common type is cholesterol gallstones yellow-gray (up to 80%). They consist mainly of undissolved cholesterol, but may contain other components as well.The second type is pigmented gallstones , brown or black stones with a predominance of bilirubin.

The exact reason for the formation of stones in the gallbladder is still being established, according to available data, they appear when an excess concentration of bile occurs in the gallbladder and an imbalance of the substances contained in it .

Causes of the formation of gallstones

When there is too much cholesterol in the bile

Usually, bile contains a sufficient amount of chemicals that dissolve the cholesterol secreted by the liver.But if your liver secretes more cholesterol than can be dissolved in bile, the excess cholesterol can be converted into crystals and eventually cholesterol stones.

When there is too much bilirubin in the bile

Bilirubin is a chemical that is produced when red blood cells (erythrocytes) are destroyed in the body. Certain conditions can stimulate your liver to produce too much bilirubin, including cirrhosis of the liver, biliary tract infections, and some types of anemias.Excess bilirubin contributes to the formation of pigment stones.

When there are gallbladder emptying disorders and bile stasis

If the gallbladder is not emptied completely or frequently enough, bile can become very concentrated, which contributes to precipitation and the formation of gallstones.

When there is a bacterial infection in the gallbladder

A chronic inflammatory process in the gallbladder leads to disturbances in its work and a change in the composition of bile and the formation of pigmented gallstones.

Risk factors for the formation of gallstones

There are factors that increase the risk of gallstones, and they differ depending on the type of stones.

Risk factors for the formation of cholesterol gallstones

• family predisposition;
• female;

90,058 age 40 and older;

• congenital structural features of the gallbladder;
• sedentary lifestyle;
• diet high in fat and simple carbohydrates;
• high cholesterol, low fiber diet;
• overweight or obese;
• pregnancy;
• fast weight loss.
• type 2 diabetes mellitus;
• taking medications containing estrogen, for example, contraceptives or hormones, and medications that affect the contractility of the gallbladder.

Risk factors for the formation of pigmented gallstones

• old age;
• the presence of diseases of the liver, blood and intestines;
• biliary tract infections and helminths.

How to reduce the risk of gallstones?

You can reduce your risk of gallstones with simple means, both on your own and with the help of your doctor.

Don’t skip meals . Try to stick to your regular meals every day. Skipping meals or fasting can increase your risk of gallstones.

Lose weight slowly . If you need to lose weight, take your time. Rapid weight loss can increase your risk of gallstones. Aim to lose 0.5-1 kilograms per week.

Include dietary fiber in your diet. It is recommended to consume up to 30 g of dietary fiber per day.Most of the fiber is found in cereals, slightly less in fruits. Whole grain bread, whole grain pasta, whole grain or large cereal porridge are the staples of the diet for a patient at risk of cholelithiasis.

Maintain a healthy weight . To lose weight, use a calorie-reduced diet and increase your physical activity. Once you’ve lost your weight, keep eating healthy and stay active.

Get medical attention . If there is a predisposition to the development of gallstone disease, observation of a gastroenterologist and preventive therapy in most cases will help to avoid the formation of stones in the gallbladder.

City Clinical Hospital No. 31 – Gallstones

Many women carry gallstones. Is it always necessary to remove the gallbladder in this case? Is there an alternative to surgery?

Says the head of the Department of Hospital Surgery of the Russian State Medical University, surgeon of the 31st City Clinical Hospital.Moscow Doctor of Medical Sciences, Professor Sergei Georgievich Shapovalyants .

– Is it necessary to remove the gallbladder if there is only one small stone in it? Is it worth sacrificing an entire organ?

– This question is asked by many patients, because few people want to immediately take drastic measures. They believe that small gallstones are not dangerous and can be simply watched. And sometimes this tactic is actually used.However, we must admit it is very, very dangerous. Even small stones can cause serious complications. If large formations can lead to bedsores, breaks of the gallbladder, then small stones are insidious in their own way. They can migrate and enter the bile ducts. Wandering along them, the stones reach the level of the confluence in the duodenum and get stuck there. Due to a violation of the outflow of bile, the pigment bilirubin begins to accumulate in the blood, and obstructive jaundice occurs. In addition, severe acute pancreatitis can develop rapidly.In this case, there is no time for thought – an ambulance is needed.

All patients should also know that if a stone appears in the gallbladder, it will never completely dissolve. The presence of even the smallest stones indicates that the work of the gallbladder is disrupted, bile begins to precipitate. And if this trend has appeared, it will develop.

– But there is a method of dissolving stones with the help of medicines. Why not try it before you go to the surgeon?

– Indeed, there are drugs with which one can try to influence some gallstones.But not completely dissolve them – this does not happen, but only slightly reduce their size. This can be done only with a strict combination of the size of the stone, its chemical composition, contractile function of the gallbladder and drug tolerance.

Bile acids are used to dissolve stones. Two of them are used as drugs – chenodeoxycholic acid and ursodeoxycholic acid. These drugs are marketed by many companies under different names. Some of the most famous are Henofalk and Ursofalk.With the help of these funds, you can act exclusively on cholesterol stones. If the stones contain a lot of calcium or bilirubin, then the use of bile acids is useless. They never dissolve these substances.

Gallstones should be no more than 2 cm in diameter. Larger formations, of course, can be tried to be reduced. However, this will take a very long time, up to several years, because on average stones are reduced by 1 mm per month.

In addition, stones can be dissolved only if the function of the gallbladder is preserved, when it continues to contract normally and excrete bile.And in acute inflammatory diseases of the gallbladder and bile ducts, in liver diseases, gastric and intestinal ulcers, this is contraindicated and pointless.

It should be said that the intake of bile acids is very often accompanied by undesirable reactions, in particular, upset stools. But despite this, the patient must take these drugs regularly and for a long time, at least several months. One has only to stop the treatment – and the stones grow again.So the drug method has very limited effectiveness.

-What can you say about the method of crushing gallstones? Crushed kidney stones?

– Analogies between the cleavage of kidney and gallstones are actually drawn often. At one time, stones in the gallbladder were crushed by extracorporeal lithotripsy. Moreover, this method was very popular. During the lithotripsy session, multiple shock waves were sent to the stone outside the body. As a result of this impact, the stone was crushed into fragments.Then small fragments left the body on their own through the bile ducts and intestines. At the same time, large fragments that could not pass through the duct remained in the gallbladder.
But that’s half the trouble. The fragments formed as a result of crushing often got stuck in the bile ducts, clogged them and disrupted the entire process of bile secretion.

There is one more important point. Before lithotripsy, stones are usually even, smooth, adapted to the shape of the gallbladder.And a person often does not feel them. As soon as you crush it, turn it into a mass of small but sharp fragments, biliary colic and jaundice appear, and the pancreas becomes inflamed. The patient’s position can be severely deteriorated. So this method can be considered simply dangerous, and many foreign and domestic clinics refuse it.

– Clearly, all conservative methods do not bring much success. But if one decides to have an operation, why is it necessary to remove an entire organ? Is it possible to remove only stones and leave the gallbladder?

– Alas, this method is now recognized as ineffective, although in some places it is still practiced.There is an opinion that some patients, especially young ones, should not have their gallbladder removed. Still, it performs certain important functions in the body.

Proponents of this approach perform an operation during which a small incision is made in the gallbladder. Through it, gallstones are taken out, then the bladder is sutured, and after two or three days the satisfied patient returns home. No stones, and the gallbladder was in place.

However, not everything is so simple. Approximately 2-3 months after such an operation, gallstone disease raises its head again.The same symptoms and complications return as the person had before the intervention. The relapse rate at different intervals reaches almost 100%. This is due to the fact that one of the prerequisites for the formation of stones in the gallbladder is its poor contractility. Such a bubble is called stagnant. Another reason is the innate features of the bile structure. When bile, in any diet, even a purely vegetarian one, is concentrated and precipitated. In this case, removing only stones is simply meaningless.The problem can be finally solved only by completely eliminating the gallbladder.

– Does this always require abdominal surgery?

– Of course not. In large clinics and hospitals, removal of the gallbladder is performed by laparoscopy. The operation is performed through three or four punctures in the abdominal wall. An optical system is introduced inside. The abdominal cavity is examined and the gallbladder is removed with special instruments.

As a rule, this is where all the patient’s troubles end.After a short period of adaptation, he can forget about gallstone disease forever. Moreover, the absence of a gallbladder will remain almost invisible for him. Indeed, in fact, his “biological loss” occurred much earlier – even at the stage of formation of stones. Even then, the gallbladder ceased to function normally, and other parts of the biliary system began to perform its work.

– Honestly, I know of cases when after such an operation people felt no better, but even worse … What can you say about this?

– You are right, there is such a thing as postcholecystectomy syndrome.It implies just the deterioration in well-being that you are talking about. Most often this happens if the operation is performed at an already advanced stage of the disease. When neighboring organs are involved in the inflammatory process. In this situation, only one thing can be said – do not push it to extremes. Do the surgery as planned, not when the thunder breaks out.

But there is another reason for the poor condition. And this is a rather serious problem with deep roots. The fact is that the operation to remove the gallbladder began to be considered technically simple for doctors and quite easily tolerated for patients.For these reasons, many people go to it without much hesitation. Although in reality it is not always worth doing this.

The circle of passed examinations of the patient is often limited to one ultrasound of the abdominal cavity. Moreover, according to its results, a person may not have stones as such, but “clots” or “suspensions” are found. True, the patient presents some complaints similar to the symptoms of gallstone disease. It is they who are taken as the basis for the decision.

The patient is operated quickly, and the operation does not bring relief.The question arises: was the gallbladder really the cause of poor health? After all, the same symptoms can occur due to other problems, in particular, due to duodenal dyskinesia. And if in such a situation the gallbladder is removed – a kind of buffer that softens unpleasant manifestations – then the existing problems will immediately worsen. Pain syndrome will appear, the whole complex of symptoms will emerge.

– What to do in such a situation?

– Sadly – to open a new case history.In general, in order to avoid such a development of events, before the operation, it is necessary to undergo a thorough examination not only of the gallbladder, but also of all organs located nearby. It is necessary to carefully assess the state of the bile ducts, pancreas, duodenum, right kidney, stomach. Not all medical institutions are equipped with the necessary equipment for this. Therefore, it is better to go to large clinics and centers.

Endoscopic ultrasonography of the bile ducts is now successfully used in cases of suspected stones.After all, if there are also pebbles there, then first you need to eliminate them, and only then take up the gallbladder. In order to avoid those very complications.

Computed tomography will help to examine the liver and pancreas. A biochemical blood test will tell you many necessary details. Of course, not everyone needs this research. But if there are any doubts, they cannot be ignored.

So take a closer look at yourself. Take drastic measures deliberately and trusting your doctor.

Please note! The prerequisites for the occurrence of gallstone disease are:

1. Overweight;

2. Sedentary lifestyle;

3. Pregnancy.

Make an appointment with our specialists

You can make an appointment for a paid appointment to the doctor by calling of the Consultative and Diagnostic Center +7 (499) 936-99-89 , or by filling out the form presented.

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Choledocholithiasis: stones in the bile ducts operation

Choledocholithiasis is one of the forms of manifestation of gallstone disease, in which calculi are found not in the gallbladder, but in the bile ducts. Most often – in the common bile duct, common bile duct.

Moreover, they either get there from the gallbladder, or are formed directly in the common bile duct. As a rule, the treatment of such a disease is prompt.Note that the disease is quite serious, especially in those cases when serious complications develop in the form of a blockage of the duct, then there is a threat to the patient’s life.

How do stones appear in the bile duct?

They usually form in the gallbladder and travel with the flow of bile through the cystic duct. At the same time, the general appearance of stones in the bladder and in the ducts, their microstructure and chemical composition are identical. Evidence of the gallbladder origin of calculi is the presence of edges on their surface, which are formed as a result of the contact of several stones in the gallbladder.The wider the diameter of the cystic duct, the greater the likelihood of stones moving into the common bile duct. In some cases, stone formation can occur directly in the lumen of the common bile duct itself. This occurs when the outflow of bile through the ducts is difficult.

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

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

Diagnosis of choledocholithiasis (stones in the bile ducts)

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

In the presence of small (less than 5-7 mm) stones in the gallbladder in any patient with gallstone disease, the presence of stones in the common bile duct should be suspected, since such sizes allow them to migrate freely through the cystic duct.You should especially be on your guard with bilirubinemia (even a slight increase in serum bilirubin). Usually, the level of alkaline phosphatase increases at the same time, an increase in the level of aminotransferases is likely. However, after the obstruction (blockage) has been removed, aminotransferase levels usually return to normal quickly. While bilirubin levels often remain elevated for 2 weeks, elevated alkaline phosphatase levels remain even longer.

Laboratory diagnostics.

Asymptomatic choledocholithiasis may not be accompanied by changes in laboratory tests. With the development of inflammation in the blood, the level of leukocytes and ESR increases. If the outflow of bile is impaired, an increase in the concentration of bilirubin is observed (due to the direct fraction), an increase in the level of aminotransferases (transaminases) and alkaline phosphatase in the biochemical analysis of blood, an increase in the content of bile pigments in the urine. Stercobilin may be absent in the feces. A very formidable laboratory symptom is an increase in blood amylase, as this indicates damage to the pancreas.

Instrumental diagnostics.

Ultrasound examination of the abdominal organs (ultrasound) is the most accessible method for examining the biliary tract, in fact a screening method. Its sensitivity for detecting the expansion of the common bile duct is up to 90%. However, it is not always possible for a specialist in ultrasound diagnostics to examine the terminal section of the common bile duct (the zone of confluence of the common bile and pancreatic ducts, and their confluence into the duodenum), i.e.That is, the department is very important for making the correct diagnosis. The examination can interfere with gas or liquid (even in small quantities) in the intestine.

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

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

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

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

• ERCP – a standard method for diagnosing choledocholithiasis, in the hands of an experienced endoscopist, it is effective in 90 – 95% of cases. However, this method is associated with the possible development of serious complications: hyperamilasemia, cholangitis, pancreatitis, retroperitoneal perforation of the duodenum, bleeding.Therefore, its use must be justified.
• Percutaneous transhepatic cholangiography is used in patients with obstructive jaundice when it is impossible to perform retrograde cholangiopancreatography. In this case, under the control of an ultrasound or X-ray unit, an expanded duct of the right or left lobe of the liver is punctured through the skin. After evacuation of bile, a contrast agent is injected into the lumen of the bile duct and a series of images is taken. This allows you to get a clear image of the biliary tract, determine the cause of obstructive jaundice and the level of obstruction.

Additional methods of examination include computed tomography and video duodenoscopy.

• Computed tomography (CT) of the abdominal cavity is used if there is a suspicion of compression of the bile ducts from the outside, or the presence of a neoplasm in their lumen.
• Videoduodenoscopy – endoscopic examination, in which a special endoscope with lateral optics is used, which allows a good examination of the area of ​​the large duodenal papilla or “papilla of Vater” (the place where the bile ducts enter the duodenum).This is a very important study, since sometimes the cause of choledocholithiasis is the pathology of the Vater papilla (inflammation, cicatricial stricture, tumor, or wedged calculus).

Main manifestations of choledocholithiasis

• Attack of biliary colic.
  Concrements in hepaticoholedochus injure its wall. Damage to the mucosa occurs especially easily in the narrowest part – in the area of ​​the large duodenal papilla.Therefore, the main and most striking symptom of hepatic colic is pain. The sensation of pain in choledocholithiasis practically does not differ from colic in cholecystolithiasis. Its irradiation to the back or lower back is characteristic. The pain can become shingles in the event that the overlap with calculus occurred in the area of ​​the Vater papilla, located in the duodenum 12. In this case, there is a violation of the outflow of both bile and pancreatic juice, as a result, the pancreas suffers.

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

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

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

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

More about complications of choledocholithiasis

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

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

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

Stones in the bile ducts – operation

Treatment of choledocholithiasis can only be surgical. However, this does not mean that a large operation with a large incision in the abdomen must be performed.
Most often, with choledocholithiasis, the removal of calculi of the bile ducts is carried out by the endoscopic method.

In the hospital, the patient undergoes ERCP to clarify the presence of a stone, its localization and other parameters.If the diagnosis of choledocholithiasis is confirmed, this study turns from diagnostic to therapeutic. Dissection of the narrowed zone of the Vater’s papilla (papillosphincterotomy), crushing of stones (lithotripsy) or their removal (extraction) is performed. The surgeon’s tactics depend on the size of the stone. Stones more than 2 cm are usually crushed, less than 1 cm more often go away on their own within 2 days. But as practice shows, in most cases, in order to remove or ensure the independent passage of stones, one has to resort to endoscopic papillosphincterotomy.This is rarely avoided.

When it is impossible to remove the stone endoscopically, they resort to surgery. The operation is performed by the classical method or by laparoscopy. During the operation, the common bile duct is dissected (choledochotomy) with a special instrument and the stones are removed. In all cases of choledocholithiasis treatment, the gallbladder is removed at the same time (if it has not been removed earlier). In the future, after surgical treatment, it is necessary to undergo a postoperative examination, follow the recommendations on the regimen, diet and medication, which will be prescribed by the attending physician in the hospital.

In any case, the tactics of examination and treatment should be determined by a specialist and directed from simple methods of diagnosis and treatment to more complex ones.

Our Clinic provides a full range of diagnostics, surgical and endoscopic treatment of gallstone disease and its complications. Surgical treatment in most cases is minimally invasive using laparoscopic and endoscopic technologies.

Cholelithiasis (GSD) – Surgical department – Clinical departments – Departments and specialists – Central Clinical Hospital “RZD-Medicine”

Gallstone disease is a common disease that develops in people over the age of 40.This disease is especially often observed among the urban population of industrially developed countries. According to most researchers, about 10% of men and up to 25% of women in Europe suffer from cholelithiasis.

With gallstone disease, calculi (stones) are formed in the gallbladder and bile ducts. These stones are composed of the usual components of bile – bilirubin, cholesterol, calcium salts. Most often, there are mixed stones containing the specified components in a greater or lesser proportion.If the calculus is 90% cholesterol, then such a stone is called “cholesterol”, if from bilirubin – “pigment”, and if from calcium salts – “lime”. The size and shape of stones in gallstone disease can be different. Sizes generally vary from 1–2 mm to 3–5 cm; the shape can be round, oval, polyhedron, etc.

Causes of gallstone disease

The main place of formation of gallstones is the gallbladder, in very rare cases – the biliary tract.Currently, there are three main reasons for their formation in clinical medicine: stagnation of bile in the bladder, metabolic disorders, inflammatory changes in the wall of the gallbladder . With metabolic disorders, there is a change in the ratio of the concentrations of cholesterol, phospholipids (lecithin) and bile acids in bile. The concentration of cholesterol increases, while the concentration of phospholipids decreases. Such bile is considered to be lithogenic. Under such conditions, bile cholesterol easily precipitates in the form of crystals, these crystals group, combine with each other, which leads to the formation of stones.It is known that gallstone disease often develops in patients with metabolic diseases such as diabetes, obesity, and hemolytic anemia. With prolonged stagnation of bile in the bladder, it becomes infected. Infection leads to damage to the wall of the gallbladder, desquamation of its epithelium. All this contributes to a more rapid deposition of cholesterol crystals and the formation of gallstones. In the damaged wall of the gallbladder, the process of absorption of some components of bile is disrupted, their physicochemical ratio changes, which also contributes to stone formation.In addition, with cholestasis in the bile in the gallbladder, the concentration of cholesterol, bilirubin, calcium may increase, which increases the lithogenicity of bile. This is facilitated by the intake of cholesterol-rich food, obesity, and oral contraceptives.

Clinical manifestations of gallstone disease

Gallstone disease can be asymptomatic (the so-called latent form of gallstone disease). In this case, stones in the gallbladder are detected as an accidental finding when examining patients for another disease.

Patients with gallstones may be worried about dyspeptic disorders : an unpleasant metallic taste, bitterness in the mouth, nausea, bloating, a feeling of heaviness in the right hypochondrium, especially after eating fatty foods. Such phenomena are caused by a violation of the motility of the biliary tract and the gastrointestinal tract with the throwing of bile into the stomach and esophagus. This form of gallstone disease is called dyspeptic.

The classic clinical manifestation of cholelithiasis is hepatic (biliary) colic, which is characterized by intense cutting, stabbing, tearing, less often paroxysmal pain in the right hypochondrium and epigastric region.These pains often radiate to the lumbar region, right shoulder blade, right forearm. Also, pain can spread to the region of the heart and be mistakenly perceived as an attack of angina pectoris. Pain occurs most often after an error in the diet (intake of fatty, spicy foods), with physical exertion, psycho-emotional overstrain, shaking driving. The occurrence of pain is associated with the movement of stones in the biliary tract and their infringement in the neck of the gallbladder or cystic duct, increased pressure in the gallbladder or ducts as a result of impaired outflow of bile.Often an attack of hepatic colic is accompanied by nausea and repeated vomiting with an admixture of bile, which does not bring relief to the patient. Colic can last from a few minutes to several hours. At the same time, patients are restless, often change their posture, trying to find a comfortable position in which the intensity of pain decreases. This form of gallstone disease is called painful paroxysmal.

Diagnosis of gallstone disease

The diagnosis of gallstone disease is made on the basis of: patient complaints, medical history, physical examination by a doctor, and mainly according to instrumental examination data.At the same time, to make a diagnosis, it is often enough to conduct only one ultrasound examination (ultrasound) of the abdominal organs, in which calculi are found in the lumen of the gallbladder or in the ducts. The examination of the patient can also be supplemented with an X-ray examination. In this case, radiopaque techniques are used, such as oral cholecystography or intravenous cholecystocholangiography. In the first method, the patient takes a special X-ray contrast agent inside a few hours before the X-ray is taken, which is captured by the liver cells and released into the bile.With cholecystocholangiography, a X-ray contrast agent is injected intravenously, it is also captured by the liver cells and excreted into the bile. After contrasting, an X-ray is taken and if a defect in the filling of the lumen of the gallbladder or ducts is detected, then this may indirectly indicate the presence of calculi (stones) in them, although both polyps and a cancer of the gallbladder can give the same X-ray picture. Currently, the X-ray method for diagnosing gallstone disease is practically not used due to its low information content, low efficiency, and lack of ease of use.

Treatment of gallstone disease

Currently, surgical treatment is the only possible way to radically get rid of gallstone disease.

Until now, there are no effective drugs that can cause the dissolution of calculi in the gallbladder and bile ducts. Certain drugs can dissolve only certain types of stones, but with prolonged use, they cause serious side effects and complications.

There is an alternative, less traumatic surgical method for the treatment of gallstone disease, such as extracorporeal shock wave lithotripsy. The essence of the method lies in the destruction of gallstones by a shock wave reproduced by a special device. The shock wave is strictly focused on the gallbladder, under its influence, the stones are crushed into small fragments and sand, which in some cases, together with bile, go into the duodenum. Despite the simplicity of this method of treatment and its low invasiveness, the effectiveness of the treatment remains very low even today.This is due to the fact that not all calculi lend themselves to crushing. In 10-30% of cases, fragments of destroyed stones are large and cannot come out through the natural opening of the common bile duct. In this case, they can pinch in the neck of the gallbladder and lead to a pronounced attack of hepatic colic, or get stuck in the common bile duct and disrupt the outflow of bile into the duodenum, which will lead to the development of obstructive jaundice. Both of these conditions require immediate hospitalization in a surgical hospital! The shock wave not only destroys stones, but in some cases causes serious damage to the liver and the walls of the gallbladder.The use of extracorporeal lithotripsy in patients with cholelithiasis should be carried out according to certain indications: single cholesterol (X-ray negative) stones with a diameter of no more than 3 cm, occupying no more than half of a well-functioning gallbladder. This bloodless method is especially indicated in the treatment of elderly and senile patients. Contraindications for lithotripsy are: X-ray positive stones (with the inclusion of calcium salts), stones more than 3 cm in diameter, multiple stones occupying more than half of the gallbladder, a disabled gallbladder, a history of frequent renal colic, inflammatory diseases of the hepatoduodenal zone.

To date, many methods of surgical treatment of gallstone disease have been developed. With any type of surgical treatment, complete removal of stones is performed along with the gallbladder – the main pathogenetic substrate of the disease! This completely excludes the return of the disease.

The absolute indications for surgical treatment of gallstone disease are:

• a history of severe bouts of hepatic colic;
• the presence of large stones that can cause a pressure ulcer of the bladder wall;
• the risk of developing gallbladder cancer, which occurs in 5% of patients with long-term gallstone disease;
• small bladder stones that can block the cystic duct, enter the common bile duct and cause obstructive jaundice, cholangitis, biliary acute or chronic pancreatitis.

A relative indication for surgical treatment is the presence of latent and dyspeptic forms of gallstone disease.

The main type of surgery for cholelithiasis is the traditional (open) cholecystectomy (removal of the gallbladder). At the same time, various types of approaches (incisions) are performed through the anterior abdominal wall, penetrate into the abdominal cavity. After intraoperative revision of the gallbladder, extrahepatic bile ducts, duodenum and pancreas, assessment of the nature of pathological changes, its complete removal is performed.The classical approach provides wide access to the hepatobiliary zone and a good overview of all interested organs, however, it is associated with significant tissue trauma (especially the anterior abdominal wall), which causes a rather long period of postoperative rehabilitation and a higher risk of complications from the operating room compared to minimally invasive techniques. wounds.

Currently, the most popular are minimally invasive surgical interventions in the treatment of gallstone disease, such as cholecystectomy from a mini-access and laparoscopic cholecystectomy.

Benefits of laparoscopic surgery

Pain in the postoperative period is minor, and, as a rule, is noted only on the first day.

The patient immediately after coming out of anesthesia (a few hours after the operation) can walk and take care of himself.

The length of stay in the hospital is much reduced (up to 1–4 days), as well as the terms of restoration of working capacity.

The number of incisional hernias is reduced by several times.

Laparoscopic surgery is a cosmetic operation; after a few months, the scars after punctures in most patients become almost invisible.

Cholecystitis – inflammation of the gallbladder

It often develops in cases of cholelithiasis (so-called stone cholecystitis, up to 80–90% of the total number of diseases [1]), after viral hepatitis and other infectious diseases, in the presence of a chronic focal infection (for example, tonsillitis) or parasitic diseases (for example, opisthorchiasis).The development of cholecystitis is facilitated by stagnation and changes in the composition of bile, which may be associated with dietary habits. Cholecystitis is often combined with cholangitis.

Distinguish between calculous (the presence of gallstones in the bladder) and acalculous, acute and chronic cholecystitis.

Diagnostics of the cholecystitis

• Ultrasound of the abdominal organs with examination of the gallbladder, bile ducts, pancreas.
• General and biochemical blood test.
• X-ray examination (with the development of obstructive jaundice and suspicion of calculi in the bile ducts).

Acute cholecystitis

The main signs of acute cholecystitis: paroxysmal pain in the right half of the abdomen, radiating to the right shoulder, scapula; nausea and vomiting; chills and fever; jaundice and itching of the skin are possible. A dangerous complication of acute cholecystitis is peritonitis. Cholecystostomy is shown (Greek.chole bile + kystis bladder + stoma hole, passage) – external drainage of the gallbladder when other interventions are impossible.

The presence of stones in the gallbladder is an indication for surgery.

This is due to the fact that the presence of calculi in the gallbladder can at any time lead to acute cholecystitis, its necrosis with the development of complications:

• empyema of the gallbladder – infection of the contents of the gallbladder;
• dropsy of the gallbladder – a violation of the outflow of bile, but without its infection, while the elements of bile are absorbed, and the bladder remains filled with transparent contents;
• phlegmon of the gallbladder – purulent inflammation of the wall of the gallbladder;
• subhepatic abscess;
• biliary fistula;
• peritonitis, sepsis are deadly complications that can develop with the progression of the above complications.

With the development of complications, the operation is performed on an emergency basis and is associated with a high risk of complications, and the rehabilitation period ranges from several weeks to several months !!!

Chronic cholecystitis

Chronic cholecystitis can be stoneless and calculous, from the Latin word calculus, which means stone. Calculous cholecystitis is one of the results of cholelithiasis. Chronic cholecystitis is manifested by nausea, dull pain in the right hypochondrium, etc.discomfort after eating. In the recognition of cholecystitis, laboratory data and cholecystocholangiography play an important role.

The most formidable complication of calculous cholecystitis is hepatic colic. If a medium-sized (less than 1 cm) stone does not pass in the biliary tract, plugging the flow of bile, then bile pigments enter the blood and subhepatic jaundice develops.

Colic symptoms are very similar to the onset of acute cholecystitis.However, colic is much more painful and usually begins at night or early in the morning.

After some time, the symptoms of jaundice appear: yellowing of the sclera and skin occurs – a peculiar lemon-yellow color appears, urine darkens and becomes similar to beer, and the feces noticeably brighten, up to whiteness.

Patients in this condition are subject to emergency hospitalization.

Chronic cholecystitis can be a consequence of acute cholecystitis, but it can also occur on its own.In the Russian medical literature, it is customary to distinguish the typical and atypical type of symptoms of gallbladder diseases (cholelithiasis-K 80.2 and chronic cholecystitis).

The presence of stones in the gallbladder significantly complicates the task of treatment and worsens the prognosis of diseases.

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Regional State Budgetary Healthcare Institution “Graivoron Central District Hospital”

Wednesday,
6
June
2018

Cholelithiasis

Cholelithiasis – a disease of the gallbladder and bile ducts with the formation of stones.Although, the correct name of the medical term is as “gallstone disease” – ICD-10 code: K80. The disease is complicated by defective liver function, hepatic colic, cholecystitis (inflammation of the gallbladder) and may be obstructive jaundice with the need for a surgical operation to remove the gallbladder.

Today we will consider the causes, symptoms, signs, exacerbation, what to do in case of an attack of pain, when an operation is needed. Let’s especially talk about the nutrition of patients (diet), the menu, what foods can and cannot be eaten during treatment without surgery and after it.

What is it?

Cholelithiasis is a pathological process in which stones (calculi) form in the gallbladder and ducts. Due to the formation of stones in the gallbladder, the patient develops cholecystitis.

How gallstones are formed

The gallbladder is a reservoir for bile produced by the liver. The movement of bile along the biliary tract is provided due to the coordinated activity of the liver, gallbladder, common bile duct, pancreas, duodenum.This ensures the timely flow of bile into the intestines during digestion and its accumulation in the gallbladder on an empty stomach.

The formation of stones in it occurs due to changes in the composition and stagnation of bile (dyscholia), inflammatory processes, motor-tonic disorders of bile secretion (dyskinesia).

There are cholesterol (up to 80-90% of all gallstones), pigmented and mixed stones.

1. The formation of cholesterol stones is facilitated by the oversaturation of bile with cholesterol, its precipitation, the formation of cholesterol crystals.With impaired motility of the gallbladder, crystals are not excreted into the intestine, but remain and begin to grow.
2. Pigmented (bilirubin) stones appear as a result of increased breakdown of red blood cells in hemolytic anemia.
3. Mixed stones are a combination of both shapes. Contains calcium, bilirubin, cholesterol.

Occur mainly in inflammatory diseases of the gallbladder and biliary tract.

Risk factors

There are several reasons for the occurrence of gallstone disease:

excessive secretion of cholesterol in bile

Decreased secretion of phospholipids and bile acids into bile

stagnation of bile

biliary tract infection

· hemolytic diseases.

Most gallstones are mixed. They include cholesterol, bilirubin, bile acids, proteins, glycoproteins, various salts, trace elements. Cholesterol stones contain mainly cholesterol, have a round or oval shape, layered structure, a diameter of 4-5 to 12-15 mm, localized in the gallbladder.

1. Cholesterol-pigment-calcareous stones – multiple, have edges, the shape is different. They vary considerably in number – tens, hundreds and even thousands.
2. Pigmented stones – small, multiple, hard, fragile, completely homogeneous, black with a metallic shade, located both in the gallbladder and in the bile ducts.
3. Calcium stones are composed of various calcium salts, bizarre shape, have spike-like processes, light or dark brown in color.

Epidemiology

According to numerous publications during the XX century, especially in the second half of it, there was a rapid increase in the prevalence of cholesterol, mainly in industrialized countries, including Russia.

So, according to a number of authors, the incidence of cholelithiasis in the former USSR increased almost twice every 10 years, and stones in the bile ducts were detected at autopsies in every tenth deceased, regardless of the cause of death. At the end of the 20th century, more than 5 million were registered in Germany, and in the USA more than 15 million patients with cholelithiasis, and about 10% of the adult population suffered from this disease. According to medical statistics, cholelithiasis occurs in women much more often than in men (the ratio is from 3: 1 to 8: 1), and with age, the number of patients increases significantly and after 70 years it reaches 30% or more in the population.

Increasing surgical activity for cholelithiasis during the second half of the 20th century led to the fact that in many countries the frequency of operations on the biliary tract surpassed the number of other abdominal operations (including appendectomy). So, in the USA in the 70s, more than 250 thousand cholecystectomies were performed annually, in the 80s – more than 400 thousand, and in the 90s – up to 500 thousand

Classification

Based on the characteristics of the disease adopted today, its following classification is distinguished in accordance with the stages that are relevant for it:

1. Stone formation – a stage that is also defined as latent stone carriage.In this case, there are no symptoms of gallstone disease, however, the use of instrumental diagnostic methods allows us to determine the presence of stones in the gallbladder;
2. Physicochemical (initial) stage – or, as it is also called, the pre-stone stage. It is characterized by changes in the composition of bile. There are no special clinical manifestations at this stage, the detection of the disease at the initial stage is possible, for which a biochemical analysis of bile is used for the peculiarities of its composition;
3. Clinical manifestations – a stage, the symptoms of which indicate the development of an acute or chronic form of calculous cholecystitis.

In some cases, the fourth stage is also distinguished, which consists in the development of complications accompanying the disease.

Symptoms of gallstone disease

In principle, gallstone disease can proceed for a very long time without any symptoms or manifestations. This is due to the fact that the stones in the early stages are small, do not clog the bile duct and do not injure the walls. The patient may for a long time be completely unaware of the presence of this problem.In these cases, they usually talk about stonework. When the actual gallstone disease makes itself felt, it can manifest itself in different ways.

Among the first symptoms of the disease should be noted the heaviness in the abdomen after eating, stool disturbances (especially after eating fatty foods), nausea and moderate jaundice. These symptoms may appear even before severe pain in the right hypochondrium – the main symptom of cholelithiasis. They are explained by unexpressed violations of the outflow of bile, which is why the digestion process is worse.

The following symptoms and signs are most common for gallstone disease:

1. Temperature rise. A rise in temperature usually indicates acute cholecystitis, which often accompanies gallstone disease. An intense inflammatory process in the right hypochondrium leads to the release of active substances into the blood that contribute to a rise in temperature. Prolonged pain after colic with the addition of fever almost always speaks of acute cholecystitis or other complications of the disease.A periodic rise in temperature (wave-like) with a rise above 38 degrees may indicate cholangitis. However, in general, fever is not an obligatory symptom in cholelithiasis. The temperature may remain normal even after severe lingering colic.
2. Pain in the right hypochondrium. The most typical manifestation of cholelithiasis is the so-called biliary (biliary, hepatic) colic. This is an attack of acute pain, which in most cases is localized at the intersection of the right costal arch and the right edge of the rectus abdominis muscle.The duration of an attack can vary from 10 to 15 minutes to several hours. At this time, the pain can be very severe, radiating to the right shoulder, back or other areas of the abdomen. If the attack lasts more than 5-6 hours, then you should think about possible complications. The frequency of seizures varies. It often takes about a year between the first and second seizures. However, in general, they become more frequent over time.
3. Fat intolerance. In the human body, bile is responsible for the emulsification (dissolution) of fats in the intestine, which is necessary for their normal breakdown, absorption and assimilation.In gallstones, stones in the neck or bile duct often block the path of bile to the intestines. As a result, fatty foods do not break down normally and cause intestinal disturbances. These disorders can manifest themselves as diarrhea (diarrhea), flatulence in the intestines (flatulence), and mild abdominal pain. All these symptoms are non-specific and can occur in various diseases of the gastrointestinal tract (gastrointestinal tract). Intolerance to fatty foods can also occur at the stage of stone bearing, when other symptoms of the disease are still absent.At the same time, even a large stone located at the bottom of the gallbladder may not block the outflow of bile, and fatty foods will be digested normally.
4. Jaundice. Jaundice occurs due to stagnation of bile. The pigment bilirubin is responsible for its appearance, which is normally excreted with bile into the intestine, and from there it is excreted from the body with feces. Bilirubin is a natural metabolic product. If it ceases to be secreted with bile, then it accumulates in the blood.So it spreads throughout the body and accumulates in the tissues, giving them a characteristic yellowish tint. Most often, in patients, the sclera of the eyes turn yellow first, and only then the skin. In light people, this symptom is noticeable better, and in dark-skinned people, unexpressed jaundice can be missed even by an experienced doctor. Often, simultaneously with the onset of jaundice, the urine also darkens in patients (dark yellow, but not brown). This is because the pigment begins to be excreted from the body through the kidneys. Jaundice is not an obligatory symptom in calculous cholecystitis.Also, it does not appear only with this disease. Bilirubin can also accumulate in the blood during hepatitis, liver cirrhosis, some hematological diseases or poisoning.

In general, the symptoms of gallstone disease can be quite varied. There are various stool disorders, atypical pains, nausea, periodic bouts of vomiting. Most doctors are aware of this variety of symptoms, and just in case they prescribe an ultrasound of the gallbladder to exclude gallstone disease.

Attack of gallstone disease

An attack of gallstone disease usually means biliary colic, which is the most acute and typical manifestation of the disease. Stone carriage does not cause any symptoms or disorders, and patients usually do not attach importance to unexpressed digestive disorders. Thus, the disease is latent (hidden).

Biliary colic usually comes on suddenly. It is caused by a spasm of smooth muscles located in the walls of the gallbladder.Sometimes the mucous membrane is also damaged. This most often occurs when the stone is displaced and gets stuck in the neck of the bladder. Here it blocks the outflow of bile, and bile from the liver does not accumulate in the bladder, but flows directly into the intestines.

Thus, an attack of gallstone disease is usually manifested by characteristic pains in the right hypochondrium. In parallel, the patient may experience nausea and vomiting. Often, an attack occurs after sudden movements or exertion, or after eating a large amount of fatty foods.Once during an exacerbation, stool discoloration may occur. This is due to the fact that pigmented (colored) bile from the gallbladder does not enter the intestines. Bile from the liver flows down only in small quantities and does not give an intense color. This symptom is called acholia. In general, the most typical manifestation of an attack of gallstone disease is characteristic pain, which will be described below.

Diagnostics

Identification of symptoms characteristic of hepatic colic requires specialist advice.Under the physical examination, he carried out, it means the identification of symptoms characteristic of the presence of stones in the gallbladder (Murphy, Ortner, Zakharyin). In addition, a certain tension and soreness of the skin in the area of ​​the muscles of the abdominal wall within the projection of the gallbladder is revealed. The presence of xanthomas on the skin (yellow spots on the skin formed against the background of lipid metabolism disturbances in the body) is also noted, yellowness of the skin and sclera is noted.

The results of a general blood test determine the presence of signs indicating nonspecific inflammation at the stage of clinical exacerbation, which in particular consist in a moderate increase in ESR and in leukocytosis.A biochemical blood test determines hypercholesterolemia, as well as hyperbilirubinemia and increased activity characteristic of alkaline phosphatase.

Cholecystography, used as a method for diagnosing gallstone disease, determines the enlargement of the gallbladder, as well as the presence of calcareous inclusions in the walls. In addition, in this case, the stones with lime inside are clearly visible.

The most informative method, which is also the most common in the study of the area of ​​interest to us and for the disease in particular, is an ultrasound of the abdominal cavity.When examining the abdominal cavity, in this case, accuracy is ensured regarding the detection of certain echo-tight formations in the form of stones in combination with pathological deformations that the bladder walls undergo during the disease, as well as with changes that are relevant in its motility. Signs indicating cholecystitis are also clearly visible on ultrasound.

Imaging of the gallbladder and ducts can also be performed using MRI and CT techniques for this purpose in the specified areas.Scintigraphy, as well as endoscopic retrograde cholangiopancreatography, can be used as an informative method indicating disturbances in the processes of bile circulation.

Diet for cholelithiasis

It is necessary to limit or exclude from the diet fatty, high-calorie, cholesterol-rich dishes, especially with a hereditary predisposition to cholelithiasis. Food should be frequent (4-6 times a day), in small portions, which helps to reduce the stagnation of bile in the gallbladder.The food should contain a sufficient amount of dietary fiber, due to vegetables and fruits. You can add food bran (15 g 2-3 times a day). This reduces the lithogenicity (tendency to stone formation) of bile.

The therapeutic diet for cholelithiasis lasts from 1 to 2 years. Compliance with a diet is the best prevention of exacerbations of gallstone pathology, and if you do not adhere to it, then severe complications may develop.

The consequences of non-compliance include: the occurrence of atherosclerosis, the appearance of constipation, dangerous with stones in the bladder, an increase in the load on the gastrointestinal tract and an increase in the density of bile.A therapeutic diet will help to cope with excess weight, improve the intestinal microflora and protect the immune system. As a result, a person’s mood improves, sleep is normalized.

In severe cases, non-compliance with the diet leads to ulcers, gastritis, colitis. If you want to recover from pathology without surgery, then diet is the primary requirement.

Operation

Patients should undergo elective surgery before or immediately after the first biliary colic attack. This is due to the high risk of complications.

After surgical treatment, it is necessary to observe an individual dietary regimen (frequent, fractional meals with restriction or exclusion of individually intolerable foods, fatty, fried foods), adherence to work and rest, physical education. Eliminate alcohol consumption. It is possible to have a spa treatment after the operation, provided that the remission is stable.

Complications

The appearance of stones is fraught not only with dysfunction of organs, but also with the occurrence of inflammatory changes in the gallbladder and organs located nearby.So, due to stones, the walls of the bladder can be injured, which, in turn, provokes the onset of inflammation. Provided that the stones pass through the cystic duct with bile from the gallbladder, the outflow of bile may be difficult. In the most severe cases, stones can block the entry and exit of the gallbladder, becoming stuck in it. With such phenomena, bile stagnation occurs, and this is a prerequisite for the development of inflammation. The inflammatory process can develop over several hours and over several days.

Under such conditions, the patient may develop an acute inflammatory process of the gallbladder. Moreover, both the degree of damage and the rate of development of inflammation can be different. So, both minor edema of the wall and its destruction and, as a result, rupture of the gallbladder are possible. Such complications of gallstone disease are life-threatening. If the inflammation spreads to the abdominal organs and to the peritoneum, then the patient develops peritonitis. As a result, the complication of these phenomena can be infectious-toxic shock and multiple organ failure.In this case, there is a violation of the work of blood vessels, kidneys, heart, brain. With severe inflammation and high toxicity of microbes multiplying in the affected wall of the gallbladder, an infectious-toxic shock can appear immediately.

In this case, even resuscitation measures do not guarantee that the patient will be able to get out of this state and avoid death.

Prevention

For the prevention of the disease, it is useful to carry out the following measures:

· do not practice prolonged therapeutic fasting;

· for the prevention of gallstone disease, it is useful to drink enough liquid, at least 1.5L per day;

· in order not to provoke the movement of stones, avoid work associated with a prolonged stay in an inclined position;

· follow a diet, normalize body weight;

· increase physical activity, give the body more movement;

· eat more often, every 3-4 hours, to cause regular emptying of the bladder from accumulated bile;

· women should limit the intake of estrogen, this hormone promotes the formation of stones or their increase.

For the prevention and treatment of cholelithiasis, it is useful to include in the daily diet a small amount (1-2 tsp.) Of vegetable oil, preferably olive oil. Sunflower is digested only by 80%, while olive oil is completely digestible. In addition, it is more suitable for frying because it produces fewer phenolic compounds.

The intake of vegetable fat stimulates the activity of the bile bladder, as a result of which it is able to empty itself at least once a day, preventing congestion and the formation of stones.

To normalize metabolism and prevent gallstone disease, magnesium should be included in the diet. The trace element stimulates intestinal motility and bile production, removes cholesterol. In addition, a sufficient supply of zinc is required for the production of bile enzymes.

In case of cholelithiasis, it is better to stop drinking coffee. The drink stimulates the bladder to contract, which can cause a blockage in the duct and subsequent seizure.

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