Gallstones

　　The causes of gallstones are very complex, some are unchangeable factors, some are acquired factors, and some can be reversed.

　　First, irreversible factors

　　1. Onset age: The incidence of gallstones increases with age. If onset occurs in childhood, it is often related to hemolytic or congenital biliary tract diseases. The peak age of onset is between 40 and 50 years old.

　　2. Onset gender differences: Ultrasound diagnostic studies show that the ratio of male to female onset is about 1:2, and female gallstones are more common, and the high incidence of female cholesterol stones may be related to estrogen, which can increase the secretion of cholesterol in bile, reduce the total amount and activity of bile acids, and luteolin affects the contraction of the gallbladder, causing bile stasis.

　　3. Onset and genetic, family history: The onset of gallstones shows significant differences between races, indicating that genetic factors are one of the pathogenic mechanisms of gallstone disease.

　　Second, reversible factors

　　1. Onset and pregnancy: Pregnancy can promote the formation of gallstones and the number of pregnancies is positively correlated with the incidence of gallstones. Due to the increase in estrogen during pregnancy, the composition of bile changes, which can increase the saturation of cholesterol in bile; while the gallbladder emptying during pregnancy is slow; changes in weight and diet structure during pregnancy and postpartum also affect the composition of bile, changing the enterohepatic circulation of bile acids, promoting the formation of cholesterol crystals.

　　2. Onset and obesity: Clinical and epidemiological studies show that obesity is an important risk factor for the onset of gallbladder cholesterol stones, and the incidence rate in obese people is three times that of normal weight people.

　　3. Onset and dietary factors: Diet habits are the main factors affecting the formation of gallstones. The incidence of gallstones in people who eat low-fiber, high-calorie foods is significantly increased. Because such foods increase the saturation of cholesterol in bile. With the improvement of living standards in China, the incidence of gallstones has occupied a major position in gallstone diseases, and it is mainly cholesterol stones.

　　4. Other factors: Certain drugs can cause the formation of gallstones, but if the medication is short-term, the stones can disappear; rapid weight loss (>1.5kg/wk), such as unreasonable weight loss methods, can lead to the formation of gallstones; metabolic syndromes such as diabetes and hyperlipidemia, the incidence of gallstones in patients is increased; and some special diseases, such as calcium and phosphorus metabolism disorders caused by parathyroid diseases, can also cause the onset of gallstones.

　　Gallstones, if not treated in time, may lead to serious complications and cause greater harm to patients. Common complications of gallstones include the following:

　　1. Cholangitis

　　It is one of the common complications of gallstones. Bile containing bacteria is discharged and pollutes the common bile duct, stimulating the Oddi's sphincter, causing spasm or stricture, which can lead to choledochitis. Or, due to the impaction of the stone, the intima of the common bile duct suddenly swells and thickens. If the inflammation worsens and ascending infection occurs, it can lead to suppurative cholangitis.

　　2. Gallbladder perforation

　　It is a very serious complication of gallstones. Due to acute inflammatory edema, the blood vessels in the gallbladder wall are compressed, leading to local ischemia and necrosis, causing gallbladder perforation. If it is not encapsulated by surrounding tissues, it may even lead to choleperitoneum.

　　3. Biliary bleeding

　　If patients have concurrent biliary bleeding, symptoms such as hematemesis, melena, and abdominal pain may occur, followed by jaundice. The abdominal pain is often due to increased intrabiliary pressure caused by bleeding, and spasm of the biliary wall, and when the blood enters the intestine, the intrabiliary pressure decreases and the pain is relieved.

　　4. Acute pancreatitis

　　The abdominal pain caused by acute pancreatitis is often more severe than that of cholecystitis, accompanied by severe vomiting and fever. The characteristic is that the pain does not subside after vomiting. It is often due to obstruction of the pancreaticobiliary duct, increased pressure in the main pancreatic duct, pancreatic swelling, and traction of the pancreas. The serum and urine amylase levels are significantly elevated, generally exceeding 500 Somogyi units. Blood amylase levels rise 3-6 hours after the onset, reaching a peak at 20-30 hours, and usually return to normal within 3-4 days. Urinary amylase increases less than serum amylase, but lasts longer.

　　5. Liver abscess

　　Liver abscess is caused by the inflammation of the bile duct spreading upwards to the liver, with symptoms such as chills, high fever, upper right abdominal pain, liver enlargement, etc. The pain is usually persistent and distending. During examination, tenderness and percussion pain are present in the liver and gallbladder area. In severe cases, jaundice may occur, and an X-ray examination may show increased muscle tension on the right side of the abdomen.

　　The main clinical manifestation of gallstones is upper right abdominal pain, but there may be no symptoms in the early stage. To help patients better understand this disease, the following will provide a specific introduction to its symptoms.

　　1. Gallbladder stones usually do not have obvious symptoms in the early stage, and most are found during routine physical examinations. Sometimes, mild discomfort may be mistaken for gastric disease and not seek timely medical attention.

　　2. Some solitary or multiple gallstones in the gallbladder exist freely and are not prone to impaction, rarely causing symptoms, and are known as asymptomatic gallstones.

　　3. Small gallstones in the gallbladder can become impacted at the gallbladder neck, causing clinical symptoms, especially after fatty meals when the gallbladder contracts, or when symptoms are exacerbated during sleep due to changes in body position.

　　4. When gallstones are embedded in the gallbladder neck, it causes acute obstruction, leading to increased intragallbladder pressure. Bile cannot pass through the gallbladder neck and cystic duct, thus causing clinical symptoms, usually manifested as biliary colic. It presents as persistent upper right abdominal pain, which may be exacerbated intermittently and can radiate to the right shoulder and back. Nausea and vomiting are often accompanied. Some patients may experience spontaneous relief of clinical symptoms a few hours later.

　　5. If gallbladder stone impaction persists without relief, the gallbladder will continue to enlarge, and may even lead to infection, progressing to acute cholecystitis. If not treated promptly, a small number of patients may progress to acute suppurative cholecystitis. In severe cases, gallbladder perforation can occur, resulting in serious clinical consequences.

　　Preventing gallstones is also about the causes of gallstones. People with high-risk factors for gallstones should pay attention to:

　　1. Diet should be regular and diverse. Currently, there is an increase in high-fat and high-protein diets, and there is a lack of regular diet, especially not eating breakfast. Therefore, the diet should focus on low-fat, regular, reasonable, and diverse diets. In addition, cold and greasy foods, high-protein foods, spicy foods, and strong alcohol should be eaten less.

　　2. Excessive intake of cholesterol not only increases the burden on the patient's liver but can also cause excess cholesterol to crystallize, accumulate, and precipitate on the gallbladder wall, thereby forming gallstones. Therefore, reducing cholesterol intake, limiting calorie intake, and maintaining an ideal weight have a positive significance for preventing gallstones.

　　3. It is important to ensure a healthy lifestyle. Patients should overcome unhealthy sedentary habits such as staying up late, excessive drinking, smoking, and others, drink more water, and persist in outdoor activities to maintain a good mental state.

　　4. It is necessary to develop a good habit of exercise every day, be more active, and avoid long-term sedentary behavior.

　　The current main method for diagnosing gallstones is imaging examination, among which ultrasound examination is the first choice.

　　1. Ultrasound examination

　　For functional gallbladders, ultrasound diagnosis can accurately detect the condition of gallstones inside the gallbladder, whether the gallbladder wall is thickened and whether it is uniform, and whether the gallbladder function is abnormal. The results are often accurate and reliable.

　　2. Other imaging examinations

　　Oral or intravenous cholecystography, computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP), percutaneous liver puncture cholangiography (PTC), endoscopic ultrasound (EUS), magnetic resonance cholangiography (MRCP), spiral CT cholangiography, radionuclide scanning.

　　3. Laboratory examination

　　When there is obstruction of the bile duct, the serum total bilirubin and direct bilirubin increase, urinary bilirubin increases, and urinary bilirubinogen decreases or disappears. In patients with concurrent infection, the white blood cell count and the proportion of neutrophils increase.

　　Gallbladder stones are mainly seen in adults, with more women than men, and the incidence rate increases with age after 40. The diet of gallstone patients should be regular and diverse. The specific introduction is as follows:

　　1. Gallstone patients should not eat high-cholesterol foods such as egg yolks, fatty meats, and animal internal organs.

　　2. Gallstone patients should also limit their intake of fat, and avoid foods high in fat content such as soups and mayonnaise.

　　3. Foods that produce gas, such as potatoes, sweet potatoes, beans, onions, radishes, carbonated drinks, as well as acidic fruit juices, coffee, and cola, should be avoided.

　　4. Daily food should be as light as possible, and seasonings should be used in moderation; cooking should minimize frying and frying, and more boiling, stewing, and steaming methods should be adopted.

　　5. It is forbidden to eat spicy foods such as chili and mustard greens, as well as coffee, curry, strong tea, cigarettes, alcohol, and others. Gallstone patients must also avoid overeating.

　　For asymptomatic gallstones, follow-up and observation can be performed without treatment temporarily. The treatment methods for gallstones include surgical treatment and non-surgical treatment.

　　First, Surgical Treatment

　　Common surgical methods include open cholecystectomy and laparoscopic cholecystectomy. Traditional open surgery is divided into two types: forward resection and reverse resection. If the gallbladder triangle anatomy is abnormal or inflamed, edematous, or severely adherent and difficult to separate, the method of combined forward and reverse resection can also be used to remove the gallbladder.

　　Second, Non-surgical Treatment

　　The non-surgical treatment of gallstone disease includes dissolution, extracorporeal shock wave lithotripsy, stone expulsion, and endoscopic stone removal. The first three are non-invasive, and the last one is invasive. Clinical practice shows that the lesions of gallstone disease are located in the gallbladder. Simply using the aforementioned non-surgical treatments can temporarily remove stones in some patients, but cannot cure the gallbladder itself. The recurrence of gallstones in the long term is inevitable. Therefore, when choosing non-surgical treatment for gallstone disease, caution should be exercised.

　　1. Dissolution Therapy

　　Currently, the main drugs for dissolution therapy are ursodeoxycholic acid and its derivative chenodeoxycholic acid. Indications for treatment: ① Gallstones with a diameter below 2cm; ② Gallstones that are calcium-poor and X-ray penetrable; ③ Gallbladder ducts are unobstructed, meaning that the gallbladder can be displayed as functional in the oral gallbladder film; ④ The liver function of the patient is normal; ⑤ There is no significant history of chronic diarrhea.

　　2. Extracorporeal Shock Wave Lithotripsy

　　The main indications for treating gallstones with shock wave lithotripsy are gallstones in the gallbladder, negative gallstones shown by oral gallbladder contrast, not more than 3 stones with a diameter of 12-15mm, and only 1 stone with a diameter of 15-20mm, and it is required to have a normal gallbladder contraction function.

　　3. Stone Expulsion Therapy

　　This treatment method is mainly based on the action of some traditional Chinese medicine to increase bile secretion, promote gallbladder contraction, and dilate the Oddi sphincter, combined with the understanding of modern medicine, forming a combined traditional Chinese and Western medicine stone expulsion therapy. The effective combination of traditional Chinese and Western medicine stone expulsion therapy is mainly in the common bile duct.

　　4. Contact Dissolution

　　The contact dissolution application conditions require a small number of gallstones, X-ray penetrable, good gallbladder function, and no acute inflammation.