Gallstone disease: treatment

Objectives of treatment of cholelithiasis

• Removal of gallstones (either the stones themselves from the bile ducts, or the gallbladder along with the calculi).
• Closing of clinical symptoms without surgical intervention (in the presence of contraindications to surgical treatment).
• Prevention of complications, as the nearest (acute cholecystitis, acute pancreatitis, acute cholangitis), and distant (gall bladder cancer).

The causes of the main mistakes in managing patients with cholelithiasis are the underestimation of repeated episodes of gallstone colic as a serious indication for the operative treatment of the disease, which leads to the development of acute and chronic complications of cholelithiasis, high mortality of patients with cholelithiasis.

Indications for hospitalization

In the surgical hospital: recurrent biliary colic; acute and chronic cholecystitis and their complications; acute biliary pancreatitis. Into the gastroenterological hospital:

• chronic calculous cholecystitis - for detailed examination and preparation for operative or conservative treatment;
• exacerbation of cholelithiasis and condition after cholecystectomy (chronic biliary pancreatitis, dysfunction of the sphincter of Oddi).

Duration of inpatient treatment: chronic calculous cholecystitis - 8-10 days, chronic biliary pancreatitis (depending on the severity of the disease) - 21-28 days.

Treatment includes dietotherapy, the use of medicines, methods of remote lithotripsy and operative intervention.

Non-drug cholelithiasis

Dietotherapy: at all stages recommend 4-6 meals a day with the exception of foods that increase bile secretion, secretion of the stomach and pancreas. Exclude smoked, refractory fats, irritating seasonings. The diet should include a large amount of plant fiber with the addition of bran, which not only normalizes the intestinal motility, but also reduces the bile lithogenicity. With biliary colic, hunger is needed for 2-3 days.

Drug treatment of cholelithiasis

Oral litholytic therapy is the only effective conservative treatment for cholelithiasis.

In patients with cholelithiasis, there is a decrease in the pool of bile acids. This fact served as an incentive for studying the possibility of dissolution of gallstones with the oral administration of bile acids, the results of which were successful. The mechanism of litholytic action is not to increase the content of bile acids, but to lower the cholesterol level in the bile. Chenodeoxycholic acid suppresses intestinal absorption of cholesterol and its synthesis in the liver. Ursodeoxycholic acid also reduces the absorption of cholesterol and suppresses the normal compensatory activation of cholesterol biosynthesis. In the treatment of these drugs, the secretion of bile acids does not change significantly, but the decrease in cholesterol secretion leads to desaturation of the bile. In addition, ursodeoxycholic acid increases the deposition time of cholesterol.

Drug treatment of cholelithiasis

Surgical treatment of cholelithiasis

In the asymptomatic course of cholelithiasis, as well as with a single episode of biliary colic and infrequent painful episodes, the most justified wait-and-see tactics. If there is evidence in these cases, oral lithotripsy is possible.

Indications for surgical treatment for cholecystolithiasis:

• presence of large and small concrements in the gallbladder, occupying more than 1/3 of its volume;
• the course of the disease with frequent bouts of biliary colic, regardless of the size of the stones;
• disconnected gallbladder;
• cholelithiasis complicated by cholecystitis and / or cholangitis;
• combination with choledocholithiasis;
• gallstone disease, complicated by the development of the Mirizzi syndrome;
• cholelithiasis, complicated by dropsy, empyema of the gallbladder;
• cholelithiasis complicated by perforation, penetration, fistula;
• gallstone disease, complicated by biliary pancreatitis;
• gallstone disease, accompanied by a violation of patency of the general
• bile duct.

Surgical treatment of cholelithiasis

Consultations of specialists about treatment

• Consultation of the surgeon - a decision on the operative treatment of cholelithiasis.

Further management

All patients with cholelithiasis are subject to follow-up in out-patient and out-patient settings. It is especially necessary to observe patients with asymptomatic stones. A careful clinical evaluation of the anamnesis and physical signs is shown. At occurrence of any dynamics spend laboratory inspection and US. Similar activities are performed if there is a history of a single episode of biliary colic.

When performing oral litholytic therapy, regular monitoring of the condition of stones with ultrasound is required. In the case of chenodeoxycholic acid therapy, control of functional liver samples is recommended once every 2-4 weeks.

Patient education

The patient should be informed about the nature of his illness and possible complications. We should recommend a certain regime and nature of nutrition. When oral litholytic therapy is necessary to justify the duration of treatment and the possibility of its failure. It is important to convince the patient of the need for a timely scheduled operation and to provide information about the possibility of its laparoscopic option.

Forecast

The effectiveness of conservative treatment is quite high: with proper selection of patients, complete dissolution of the stones is observed after 18-24 months in 60-70% of patients, however, recurrences of the disease are not uncommon.

Prevention

It is necessary to maintain optimal BMI and sufficient level of physical activity. A sedentary lifestyle contributes to the formation of stones in the gallbladder.

If the probability of a rapid reduction in the body weight of the patient (more than 2 kg / week for 4 weeks or more) is presumed, it is possible to administer ursodeoxycholic acid preparations at a dose of 8-10 mg / kg / day to prevent the formation of stones. Such an exercise prevents not only the formation of stones proper, but also the crystallization of cholesterol and an increase in the bile lithogenicity index.

In patients who are on prolonged complete parenteral nutrition, it is necessary to evaluate the appropriateness of intravenous administration of cholecystokinin at a dose of 58 ng / kg / day. Cholecystokinin prevents the development of a sluggish phenomenon (predisposing to the formation of gallstones) in this group of severe patients.

In some cases, and only according to strict indications, laparoscopic cholecystectomy is possible in the presence of asymptomatic stones to prevent the development of clinical manifestations of cholelithiasis or cancers of the gallbladder.

Indications for cholecystectomy with asymptomatic calcification:

• calcified ("porcelain") gallbladder;
• stones larger than 3 cm;
• the forthcoming long stay in the region with a lack of qualified medical care;
• sickle-cell anemia;
• impending organ transplantation.

The best prophylaxis of complications of SCI is timely surgical treatment.

Screening of cholelithiasis

Conduction of ultrasound is indicated for persons with an increased likelihood of developing cholelithiasis and gallbladder cancer: patients with an increased BMI leading a sedentary lifestyle; patients complaining of a feeling of discomfort in the right hypochondrium and epigastric regions, and also to all patients who have risk factors for cholelithiasis.

[1], [2], [3], [4], [5], [6], [7]