Causes, Symptoms and Methods of Treating Gallstones
- What is gallstone disease?
- Symptoms of gallstones
- Causes of the formation of stones in the gallbladder
- What size do the stones reach?
- Diagnostics of ZhKB
- Methods for treating gallstones
- Removal of the gallbladder (cholecystectomy)
- Diet for gallstone disease
- Prevention of gallstone disease
What is gallstone disease?
Cholelithiasis (GSD) is a disease characterized by the formation of stones in the gallbladder and its ducts due to the violation of certain metabolic processes. Another name for the disease is cholelithiasis.
The gallbladder is an organ adjacent to the liver and acts as a reservoir for the liquid bile produced by the liver. Gallstones, or calculi, can be found both in the gallbladder itself and in its ducts, as well as in the liver and the trunk of the hepatic duct. They differ in composition and can have different sizes and shapes. Gallstone disease often provokes the development of cholecystitis (inflammation of the gallbladder), since the stones irritate its walls.
Concretions in the gallbladder are formed from cholesterol crystals or calcium pigment-calcareous salts (in more rare cases). Biliary colic occurs when one of the stones blocks the duct that carries bile from the bladder to the small intestine.
The formation of stones in the gallbladder is a fairly common disease, which affects about 10% of the adult population in Russia, Western Europe and the United States, and in the age group over 70 years old, this figure reaches 30%.
In the second half of the twentieth century, the frequency of surgical interventions performed on the gallbladder surpassed the frequency of surgical operations to remove appendicitis.
Gallstone disease is predominantly found among the population of industrialized countries, where people consume large quantities of food rich in animal proteins and fats. According to statistics, in women, cholelithiasis is diagnosed 3-8 times more often than in men.
Symptoms of gallstones
In most cases, gallstone disease is asymptomatic and has no clinical manifestations for several (usually five to ten) years. The appearance of symptoms depends on the number of stones, their size and location.
The main signs of gallstone disease are:
- Paroxysmal drilling or stitching pains in the liver and right hypochondrium;
- Nausea, in some cases vomiting;
- Bitter taste in the mouth due to flow of bile into the stomach, belching with air;
- Flatulence, problems with stools (constipation, diarrhea), discoloration of feces;
- Weakness, general malaise;
- Temperature increase;
Hepatic (biliary) colic usually develops after eating fatty, heavy food, spicy and fried foods, alcohol, as well as in conditions of increased physical or stressful stress. Pain sensations begin on the right under the ribs, can be given to the right hand (shoulder and forearm), scapula, lower back, right half of the neck. Sometimes the pain can spread behind the sternum, which looks like an attack of angina pectoris.
The pain appears due to a spasm of the muscles of the gallbladder and its ducts, which occurs in response to irritation of the walls of the bladder with stones, or due to excessive stretching of the walls of the bladder as a result of excess bile accumulated in it.
Severe pain syndrome is also noted when stones move along the biliary tract and when stones block the lumen of the bile duct. Complete blockage leads to enlargement of the liver and stretching of its capsule, which causes constant dull pain and a feeling of heaviness in the right hypochondrium. In this case, obstructive jaundice develops (the skin and sclera of the eyes acquire a yellow color), which is accompanied by discoloration of feces. Other symptoms of a complete blockage of the duct include fever, increased sweating, fever, and seizures.
Sometimes biliary colic clears up on its own after the stone passes through the bile duct into the small intestine. The attack usually lasts no more than 6 hours. To relieve pain, you can apply a heating pad to the area of the right hypochondrium. If the stone is too large, it cannot leave the bile duct itself, further outflow of bile becomes impossible and the pain intensifies, immediate surgical intervention is required.
A common symptom of gallstone disease is vomiting with an admixture of bile, which does not bring a feeling of relief, since it is a reflex response to irritation of some areas of the duodenum.
An increase in temperature to subfebrile values (not higher than 37 ° - 37.5 ° C) indicates the addition of infection and the development of an inflammatory process in the gallbladder. The development of cholecystitis is accompanied by a decrease in appetite and increased fatigue.
The first symptoms of gallbladder problems that should not be ignored are:
Causes of the formation of stones in the gallbladder
Healthy bile has a liquid consistency and does not form stones. The factors provoking their formation include:
- An increased level of cholesterol in the bile composition, due to which its properties change;
- Violation of the outflow and stagnation of bile;
- Getting into the gallbladder of infection and the subsequent development of cholecystitis.
The main reason for the formation of calculi is a violation of the composition of bile - the balance between cholesterol and bile acids. Bile with an excess of cholesterol and a deficiency of bile acids is called lithogenic.
The increased content of cholesterol in bile is due to the following reasons:
- Excessive consumption of foods with high cholesterol levels (animal fats);
- Dysfunction of the liver, when the production of bile acids decreases;
- The presence of obesity, which is observed in about 2/3 of patients;
- Long-term use of oral contraceptives containing estrogens (in women);
- The presence of other diseases such as diabetes mellitus, hemolytic anemia, cirrhosis of the liver, allergies, Crohn's disease and other autoimmune conditions.
With a decrease in the contractile function of the gallbladder, cholesterol flakes settle, from which later clots form - cholesterol stones.
The reasons for the obstructed outflow of bile and its stagnation are the following factors:
- The presence of certain diseases: dyskinesia (impaired contractile function) of the biliary tract, flatulence (increased pressure in the gastrointestinal tract complicates the flow of bile), as well as a history of surgical interventions on the gastrointestinal tract (vagotomy, etc.);
- Pregnancy (the pressure of the uterus on the peritoneal organs also prevents the outflow of bile);
- Incorrect diet with significant intervals between meals, as well as fasting and drastic weight loss.
In addition to functional genesis (dyskinesia), stagnation of bile can be caused by mechanical reasons, that is, by the existence of obstacles in the path of its movement: these include adhesions, tumors, edema of the bladder walls, bending or narrowing of the bile duct, as well as congenital anomalies: cysts of the main bile duct, diverticula (bulging of the walls) of the duodenum.
And finally, the third reason is infection of the gallbladder, which occurs ascending from the intestine or through the blood and lymph flow and as a result leads to cholecystitis (inflammation of the mucous membrane of the bladder walls) and cholangitis (inflammation of the bile ducts). Chronic cholecystitis and cholelithiasis are interdependent conditions, when one of the diseases supports, accelerates and complicates the course of the other.
There are two types of stone formation:
- Primary stones begin to form in unchanged bile ducts and do not cause any clinical symptoms for a long time.
- Secondary stone formation occurs against the background of disturbances in the outflow of bile: cholestasis (a decrease in the volume of bile entering the duodenum), bile hypertension (an increase in pressure in the common bile duct, which leads to its expansion); due to blockage of the primary stones of the biliary tract. The formation of cicatricial stenosis and a lumen in the biliary tract leads to an ascending infection from the lower gastrointestinal tract into the gallbladder.
Thus, violations of the structural composition of bile play a decisive role in the appearance of primary calculi. Secondary stone formation is the result of cholestasis and infection of the gallbladder. Primary stones form mainly in the gallbladder due to stagnation and thick bile consistency. Secondary calculi can form both in the bladder itself and in the ducts, bile and intrahepatic.
How large are gallstones?
The gallbladder is a hollow organ located under the liver that stores bile. Bile is continuously produced by the liver, concentrated in the gallbladder and periodically enters the duodenum through the bile ducts. Bile is directly involved in the digestive process and consists of bile acids, pigments, cholesterol and phospholipids. With prolonged stagnation of bile, cholesterol precipitates, which gradually leads to the formation of the so-called "sand", the particles of which increase in size over time and combine to form larger stones.
By structure, gallstones are divided into homogeneous and complex (consisting of a nucleus, body and cortex). The nucleus usually consists of bilirubin. Homogeneous stones usually consist of clots of mucus, pure cholesterol and foreign objects (fruit pits, etc.).
By chemical composition, cholesterol, calcareous, pigment and mixed calculi are distinguished. Single component stones are relatively rare. Most stones have a mixed composition with a predominance of cholesterol. Stones with a predominance of pigments usually contain a significant proportion of lime salts impurities, therefore they are called pigment-lime. The structure of the stones can be crystalline or layered, the consistency - hard or waxy. In most cases, the gallbladder of one patient contains stones with different composition and structure.
The sizes of stones vary very widely, from a few millimeters to several centimeters, and can reach the size of a hazelnut or a chicken egg. Sometimes one stone occupies the entire cavity of the distended gallbladder and weighs up to 70-80 grams. The form of gallstones can also be any.
Stones with a diameter of 1-2 mm can pass through the bile ducts; in the presence of larger stones, the consequences and symptoms described above occur. In medicine, the fact is recorded when one gallbladder contained about 7000 stones.
- Acute cholecystitis;
- Blockage of the biliary tract with the subsequent addition of infection and the development of chronic cholecystitis and pancreatitis;
- Perforation (rupture) of the gallbladder and its consequences in the form of peritonitis;
- The ingress of large stones into the intestines and intestinal obstruction;
- The risk of an oncological process in the gallbladder.
Diagnostics of ZhKB
The presence of stones in the gallbladder is established on the basis of an ultrasound examination. Large stones can be identified by touch. With the help of ultrasound, the number, size and localization of stones is determined, and the condition of the gallbladder is also diagnosed (for example, thickening of its walls indicates an inflammatory process).
If the diagnosis is difficult, more sophisticated methods are used, which include oral cholecystography (x-ray after oral administration of drugs that contrast bile), retrograde cholangiopancreatography (x-ray with endoscopy and the introduction of contrast into the bile ducts).
Methods for treating gallstones
Modern conservative treatment that preserves the organ and its ducts includes three main methods: dissolution of stones with drugs, crushing stones with ultrasound or laser, and percutaneous cholelitholysis (invasive method).
Medicated stone dissolution (oral litholytic therapy)
The dissolution of stones is carried out with the drugs Ursosan (ursodeoxycholic acid) and Henofalk (chenodeoxycholic acid). These drugs lower cholesterol in bile and increase bile acids.
Litholytic therapy is indicated in the following cases:
- The stones are of a cholesterol nature. The chemical composition of stones can be determined using duodenal intubation (duodenal ulcer) or oral cholecystography;
- The stones are small (from 5 to 15 mm) and fill no more than 1/2 of the gallbladder;
- The contractile function of the gallbladder is normal, the patency of the bile ducts is good;
- The patient can take acids regularly for a long time.
In parallel, you should stop taking other drugs that provoke stone formation: estrogens that are part of contraceptives; antacids, which are used for ulcers to reduce acidity and will interfere with the absorption of acids; cholestyramine, designed to bind and remove cholesterol.
Most diseases of the gastrointestinal tract and kidneys are contraindications to this method. Doses and duration of admission are prescribed by the doctor on an individual basis. The course of treatment lasts from 6 to 24 months (minimum) and is carried out under ultrasound control. The effectiveness of therapy depends on the dose of the medication and the size of the stones and is 40-80%. In parallel, you need to lead a correct lifestyle and observe preventive measures to prevent the formation of new stones.
This method is characterized by a high relapse rate after completion of treatment (up to 70%), since after stopping the drug, the cholesterol level in the bile rises again. Therefore, as a preventive measure, you will have to continue to take low (maintenance) doses of these drugs.
On the subject: Preparations for dissolving stones in the gallbladder
Ultrasonic extracorporeal lithotripsy
This method is based on crushing stones under the influence of high pressure, which is created by means of a shock wave. Ultrasound breaks the stones into smaller particles up to 3 mm in size, which are further removed through the bile ducts into the duodenum.
In practice, extracorporeal lithotripsy is often combined with the previous method, that is, the resulting small stones are dissolved using medications (Ursosan or Henofalk). The laser method works in a similar way, when calculi in the gallbladder are crushed using a laser.
This method of treatment is suitable for patients who have found a small amount (up to 4 pieces) of fairly large cholesterol stones (up to 3 cm) without lime impurities in their composition or one large stone. Usually 1 to 7 sessions are performed.
- Blood clotting disorders;
- Chronic inflammatory diseases of the gastrointestinal tract (cholecystitis, pancreatitis, ulcer).
Side effects of ultrasound lithotripsy include:
- Risk of blockage of the bile ducts;
- Damage to the walls of the gallbladder by stone fragments as a result of vibration.
Any of these effects can provoke the development of an inflammatory response and, as a result, the formation of adhesions. If the ducts are blocked, an emergency operation may be required, and the results of urgent operations are usually worse than planned ones when a person undergoes preliminary examination and training.
Percutaneous transhepatic cholelitholysis
This is an invasive method that is rarely used. With its help, not only cholesterol stones dissolve, but also any others. This method can be used at any stage of the disease, and, unlike the previous two, not only in the asymptomatic course of the disease, but also in the presence of its pronounced clinical signs.
Cholelitolysis is as follows: a thin catheter is inserted through the skin and hepatic tissue into the gallbladder, through which 5-10 ml of a special drug (methyl tertiary butyl ether) dissolves stones are injected dropwise. The procedure is repeated several times within 3-4 weeks, during which time up to 90% of the stones are dissolved.
Surgical treatment is indicated for large stones and frequent exacerbations, which are accompanied by severe pain attacks, high fever and various complications. Surgery can be laparoscopic or open.
Laparoscopy of gallstones
Removal of calculi by the laparoscopic method is practiced infrequently and only in isolated clinics. In this operation, an incision of 1.5-2 cm is made on the right under the ribs to penetrate the peritoneum. With the help of a laparoscope, the location and size of the gallbladder, the state of other abdominal organs is determined.
Under video surveillance, the gallbladder is pulled up to the first incision, and an incision of 0.5-1 cm is made at its base, through which the contents of the bladder are examined. Then a special soft tube is inserted through this incision, into which the choledochoscope is inserted - this ensures that the walls of the bladder are not damaged by the choledochoscope.
The stones are removed from the bladder, while the large stones that have entered the duct are crushed into smaller ones. After removing all the stones, the choledochoscope is removed, the incision on the bladder is sutured with absorbable threads. The skin incision is sealed with medical glue.
Removal of the gallbladder (cholecystectomy)
Currently, the most common treatment for cholecystitis accompanied by cholecystitis is the removal of the gallbladder together with stones. This is explained by the fact that the cause of calculous cholecystitis lies in a metabolic disorder, which directly affects the composition of bile, therefore mechanical removal of stones will not solve the problem, they will appear again.
In laparoscopic cholecystectomy, the bladder itself is removed through small incisions up to 1.5 cm on the anterior surface of the abdomen using a laparoscope (tube with a video camera).
Its advantages over open cholecystectomy:
- Fast recovery after surgery;
- No visible scars
- Reducing the risk of developing incisional hernias;
- Lower cost.
- Obesity II-III degree;
- Too large stones;
- History of operations on the stomach, spleen, intestines and adhesions on the abdominal organs;
- Gallbladder abscess
- Diseases of the heart and respiratory system;
- Late pregnancy.
Consequences of removing the gallbladder
Surgery does not correct the symptoms of gallstone disease. Removal of the bladder is carried out due to the formation of stones in it, the cause of the appearance of which is a pathological change in the chemical composition of bile, and after the operation this reason remains valid. After cholecystectomy, patients often complain that pain in the right hypochondrium and in the liver region persists, bitterness in the mouth often appears, food has a metallic taste. The cumulative consequences of removing the gallbladder are usually called postcholecystectomy syndrome, which includes a group of symptoms directly or indirectly related to the operation performed, as well as diseases that begin to progress after it.
Cholecystectomy, according to some reports, leads to an increase in the volume of the common bile duct. If in the presence of a gallbladder this volume is 1.5 ml, then 10 days after removal it is 3 ml, and after a year it can reach 15 ml. This is due to the need for bile reserves in the absence of a gallbladder. Another consequence can be a narrowing of the common bile duct due to its trauma during surgery. This will result in recurrent cholangitis, bile congestion, and jaundice.
The main problems arise with the liver, pancreas and duodenum. Since there is no reservoir for collecting bile, its uncontrolled flow into the intestine begins, while the lithogenicity (violation of the chemical composition) of bile remains. The duodenum becomes accessible to bacteria, which leads to a violation of the metabolism of bile acids, as a result of which they strongly irritate the intestinal mucous membranes. This contributes to the development of duodenitis, esophagitis, enteritis, colitis.
Diet for gallstone disease
The composition of the diet is of great importance for this disease. It is recommended to adhere to fractional meals, eat 5-6 times a day. The intake of food itself has a choleretic effect, therefore the intake of a small amount of food into the stomach at the same hours stimulates the outflow of bile and prevents its stagnation. But with a large portion of food, the gallbladder can instinctively contract, and this will cause an aggravation.
There should be a sufficient amount of animal protein in the diet, animal fats are also not prohibited, but are usually poorly tolerated, therefore, give preference to vegetable fats. For cholelithiasis, it is beneficial to eat foods rich in magnesium.
- Lean meat and fish;
- Cheese, cottage cheese, milk with a fat content of no more than 5%;
- Cereals, especially buckwheat and oatmeal;
- Fruits and vegetables: pumpkin, carrots, zucchini, cauliflower, apples, watermelon, prunes;
- Compotes, fruit drinks, mineral water, juices from blueberries, pomegranates, quince.
It is recommended to exclude the following foods and dishes from the menu:
- Fatty meats (pork, lamb, beef) and fish, as well as lard, liver and offal;
- Sausages, smoked meats, canned food, pickles;
- Butter (limit, preferably add to porridge);
- Legumes, radishes, radishes, eggplants, cucumbers, artichokes, asparagus, onions, garlic;
- Fried, sour and spicy foods;
- Rich broths;
- Coffee, cocoa and alcohol.
On the subject: Diet for gallstones, menu for a week
[Video] Dr. Berg - STONES IN GALLBLADDER: How to get rid of?
Prevention of gallstone disease
To prevent the formation of gallstones, you should:
- Avoid rich meals high in fat and cholesterol;
- If you are overweight or obese, follow a low-calorie diet and exercise to reduce weight gradually;
- Normalize metabolic processes: reduce the production of cholesterol by the liver and stimulate the secretion of bile acids. For this, drugs such as zixorin, liobil are prescribed.
The author of the article: Gorshenina Elena Ivanovna | Gastroenterologist
Education: Diploma in the specialty "General Medicine" received at the Russian State Medical University named after N. I. Pirogova (2005). Postgraduate studies in the specialty "Gastroenterology" - educational and scientific medical center.