Chololithiasis: causes, symptoms, diagnosis, treatment
Last reviewed: 23.04.2024
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Cholithiasis implies the presence of one or more concrements (gallstones) in the gallbladder.
In the USA, 20% of people over 65 years old have gallstones, and most of the disorders in the extrahepatic biliary tract are the result of cholelithiasis. Gallstones can be asymptomatic or cause biliary colic, but without dyspepsia. Other major complications of cholelithiasis include cholecystitis; obturation of the biliary tract (concrements in the bile duct), sometimes with infection (cholangitis); as well as biliary pancreatitis. Diagnosis is usually established using ultrasound. If cholelithiasis causes complications, it becomes necessary to perform cholecystectomy.
[What causes cholelithiasis?
Risk factors for the formation of gallstones include female sex, obesity, age, ethnicity (for the US - American Indians), Western type of nutrition and heredity.
Gallstones and bile sludge are formed from various types of substances.
Cholesterol stones account for more than 85% of gallstones in Western countries. Three conditions are necessary for the formation of cholesteric gallstones.
- Bile is supersaturated with cholesterol. Typically, water-insoluble cholesterol becomes water-soluble when combined with bile salts and lecithin. In this case, mixed micelles are formed. The hyper saturation of bile with cholesterol can be a consequence of increased cholesterol secretion (for example, in diabetes), a decrease in the secretion of bile salts (for example, in malabsorption of fat) or a deficit of lecithin (for example, in genetic disorders that cause the form of progressive intrahepatic hereditary cholestasis).
- Excess cholesterol precipitates from the solution in the form of solid microcrystals. Precipitation is accelerated by mucin, fibronectin, su globulin or immunoglobulin. Apolipoproteins A-I and A-II can slow down the process.
- Microcrystals form complexes. The process of aggregation is facilitated by mucin, reduced gallbladder contractility (which is directly a result of excess cholesterol in the bile) and slowing down the passage of contents through the intestine, which facilitates the bacterial transformation of cholic acid to deoxycholic acid.
The bile sediment consists of bilirubinate Ca, microcrystals of cholesterol and mucin. Slags are formed during congestion in the gallbladder, which is observed during pregnancy or with complete parenteral nutrition (PPP). Basically, the sludges are asymptomatic and disappear if the first condition for the formation of stones is eliminated. On the other hand, the sludge can lead to biliary colic, the formation of gallstones or pancreatitis.
Black pigmented stones are small and solid, consisting of calcium bilirubinate and inorganic salts of Ca (eg, calcium carbonate, calcium phosphate). Factors that accelerate the formation of stones include alcoholism, chronic hemolysis and senile age.
Brown pigmented stones are soft and fatty, consisting of bilirubinate and fatty acids (calcium palmitate or stearate). They are formed as a result of infection, parasitic invasion (for example, hepatic fluke in Asia) and inflammation.
Gallstones increase by approximately 1-2 mm per year, reaching 5-20 years in a size that can cause specific disturbances. Most gallstones form in the gallbladder, but brown pigmented stones can form in the ducts. Gallstones can migrate into the bile duct after cholecystectomy or, especially in the case of brown pigment stones, form above the stricture as a result of stasis.
Symptoms of cholelithiasis
In 80% of cases, gallstones are asymptomatic; in the remaining 20% the symptomatology of the disease varies from biliary colic and signs of cholecystitis to severe and life-threatening cholangitis. Patients with diabetes are predisposed to especially severe manifestations of the disease. Stones can migrate to the vesicular duct without clinical manifestations. Nevertheless, with blockage of the cystic duct, pain usually occurs (biliary colic). Pain occurs in the right hypochondrium, but can often be localized or manifested in other parts of the abdomen, especially in patients with diabetes and the elderly. Pain can radiate into the back or arm. It begins suddenly, becoming more intense for 15 minutes to 1 hour, remaining constant for 1-6 hours, then after 30-90 minutes it gradually disappears, acquiring the character of dull pain. The pain is usually strong. Often there is nausea and vomiting, but neither fever nor chills occur. When palpation is determined moderate soreness in the right hypochondrium and epigastrium, but peritoneal symptoms are not caused, and laboratory indicators are within the norm. Between episodes of pain, the patient feels well.
Although pain like biliary colic can occur after taking heavy meals, fatty foods are not a specific provoking factor. Symptoms of dyspepsia, such as belching, bloating, vomiting and nausea, are not entirely associated with gallbladder diseases. These symptoms can be observed with cholelithiasis, peptic ulcer and with functional disorders of the gastrointestinal tract.
The severity and frequency of biliary colic weakly correlate with pathological changes in the gallbladder. Bile colic can develop in the absence of cholecystitis. However, if colic lasts more than 6 hours, there is vomiting or fever, there is a high probability of developing acute cholecystitis or pancreatitis.
Where does it hurt?
Diagnosis of cholelithiasis
Suspicion for the presence of gallstones occurs in patients with biliary colic. Laboratory tests are usually not informative. Ultrasound of the abdominal cavity is the main method for diagnosing cholecystolithiasis, and the sensitivity and specificity of the method is 95%. You can also detect the presence of bile sludge. CT and MRI, as well as oral cholecystography (currently rarely used, but sufficiently informative) are alternative. Endoscopic ultrasound is especially informative in the diagnosis of gallstones less than 3 mm in size, if other methods give mixed results. The asymptomatic course of gallstones is often detected accidentally during studies performed on other indications (for example, 10-15% of calcified non-cholesterol stones are visualized on simple radiographs).
What do need to examine?
Treatment of cholelithiasis
Asymptomatic gallstones
Clinical signs of asymptomatic gallstones appear on average in 2% of patients per year. Most patients with asymptomatic cholecystolithiasis do not consider that it is worthwhile to take all the inconveniences, costs and risks of surgical intervention to remove an organ whose disease can never manifest itself clinically, despite all possible complications. However, in patients with diabetes, asymptomatic gallstones should be removed.
Gallstones with clinical symptoms
Although in most cases biliary colic occurs spontaneously, signs of biliary pathology recur in 20-40% of patients per year, and complications such as cholecystitis, choledochitis, cholangitis and pancreatitis develop in 1-2% of patients annually. So there are all indications for the removal of the gallbladder (cholecystectomy).
Open cholecystectomy, which involves laparotomy, is a safe and effective operation. If it is performed in a planned manner before the development of complications, the overall lethality does not exceed 0.1-0.5%. However, laparoscopic cholecystectomy was the method of choice. With this method of surgery, recovery is faster, with minor postoperative discomfort, cosmetic results are better, and the rates of postoperative complications or mortality do not deteriorate. In 5% of cases, because of the difficulties of complete anatomical imaging of the gallbladder or the possibility of complications in laparoscopic cholecystectomy, go to an open surgery. Elderly age generally increases the risk of any type of intervention.
In patients with biliary colic, episodes of pain after cholecystectomy usually disappear. For unexplained reasons, in a number of patients who suffer from dyspepsia and fatty food intolerance before surgery, these symptoms disappeared after the operation. Cholecystectomy does not lead to nutrition problems, and after surgery, no restrictions are required in the diet. Some patients develop diarrhea, often due to malabsorption of bile salts.
In patients who are contraindicated for surgery or the risk of surgery is high (eg, concomitant pathology or senility), it is sometimes possible to use the method of dissolution of gallstones with oral bile acid administration for several months. Stones should consist of cholesterol (radiographing with simple roentgenography of the abdominal cavity), the azalea bladder should not be blocked, which is confirmed by cholescintigraphy or, if possible, oral cholicystography. However, some clinicians believe that the stones in the neck of the bladder duct do not lead to its obturation, and therefore do not recommend performing cholecintigraphy or oral cholecystography. Uses ursodiol (ursodeoxycholic acid) 8-10 mg / kg / day orally in 2-3 divided doses; taking the main dose of the drug in the evening (for example, 2/3 or 3/4) reduces the secretion and saturation of bile with cholesterol. Due to the high ratio of surface area to volume, small gallstones dissolve more rapidly (for example, 80% of stones smaller than 0.5 cm dissolve within 6 months). At greater concrements, the efficacy is lower, even with higher doses of ursodeoxycholic acid (10-12 mg / kg / day). Approximately in 15-20% of patients stones less than 1 cm in size are dissolved in 40% of cases after 2 years of treatment. However, even after complete dissolution, stones recur in 50% of patients for 5 years. Ursodeoxycholic acid can prevent the formation of stones in obese patients who quickly lose weight as a result of a shunting operation on the stomach or after a course of a low-calorie diet. Alternative methods of dissolution of stones (injection of methyl-tributyl ether directly into the gallbladder) or their fragmentation (extracorporeal wave lithotripsy) are not currently used, since the method of choice is laparoscopic cholecystectomy.