Gallbladder stones outside the liver

　　Extrahepatic bile duct stones can be divided into primary and secondary types. The primary type accounts for the majority, referring to stones originating in the biliary tract system, most of which are bile pigment stones or mixed stones; the secondary type refers to the stones from gallstones in the gallbladder to the bile duct, most of which are cholesterol stones.

　　Infection is the primary factor leading to stone formation. The common causes of infection are biliary parasitic infection and recurrent cholangitis. Almost all bile duct stones patients can detect bacteria in bile culture; the main source of infection bacteria is the intestine, and the common bacteria are Escherichia coli and anaerobic bacteria. B-glucuronidase produced by Enterobacteriaceae and some anaerobic bacteria and endogenous glucuronidase produced during biliary tract infection can hydrolyze conjugated bilirubin to produce free bilirubin and precipitate.

　　Bile stasis is a necessary condition for the formation of intrahepatic bile duct stones. Only under the condition of bile stasis can the components of bile sediment and form stones. The causes of bile stasis include inflammatory stricture of the bile duct and biliary malformation; at the distal end of the obstructed bile duct, the pressure increases, the bile duct dilates, the bile flow is slow, which is conducive to the formation of stones.

　　In addition, large molecular substances such as mucin, acidic mucopolysaccharide, immunoglobulin, inflammatory exudates, desquamated epithelial cells, bacteria, parasites, and metal ions in bile, all participate in the formation of stones.

　　The main pathological changes of extrahepatic bile duct stones are bile duct obstruction and infection; due to the direct relationship between the biliary tract system and the liver parenchymal cells, severe cholangitis often accompanies severe liver cell damage, even leading to large areas of liver cell necrosis, which has become the main cause of death from benign biliary diseases. The complications of intrahepatic bile duct stones include acute complications and chronic complications.

　　The acute complications of intrahepatic bile duct stones are mainly biliary tract infections, including severe cholangitis, cholangogenic liver abscess, and accompanying infectious complications. The causes of infection are related to the obstruction of stones and inflammatory stricture of the bile duct. Acute complications not only have a high mortality rate but also seriously affect the outcome of surgery.

　　The chronic complications of intrahepatic bile duct stones include systemic malnutrition, anemia, hypoalbuminemia, chronic cholangitis, cholangogenic liver abscess, multiple bile duct strictures, liver lobe fibrosis and atrophy, biliary cirrhosis, portal hypertension, liver dysfunction, and delayed onset cholangiocarcinoma related to long-term biliary tract infection and bile stasis. The chronic complications of intrahepatic bile duct stones not only increase the difficulty of surgery but also affect the outcome of surgery.

　　Extrahepatic bile duct stones usually do not show symptoms in daily life or only cause discomfort in the upper abdomen. When stones cause bile duct obstruction, the typical symptoms of extrahepatic bile duct stones may appear, including abdominal pain, chills, high fever, and jaundice, known as Charcot's triad.

　　1. Abdominal pain: Sudden, severe colicky pain in the upper right abdomen or under the xiphoid process, radiating to the right shoulder and back. Accompanied by nausea and vomiting. Often triggered by eating fatty foods and changes in body position.

　　2. Chills and high fever: Occur in 2/3 of cases, occur after abdominal pain, and are related to biliary infection, toxins, or bacteria entering the blood.

　　3. Jaundice: Jaundice appears 1-2 days after abdominal pain, chills, and high fever.

　　4. In severe cases, there may be changes in consciousness or shock, which are signs of acute obstructive cholangitis or severe cholangitis and require emergency surgery.

　　5. Physical examination shows tenderness under the xiphoid process and in the upper right abdomen, percussion tenderness in the liver area. Sometimes, an enlarged gallbladder can be palpated.

　　6. Ultrasound and CT show stones in the common bile duct or common hepatic duct, and liver function tests show an increase in direct bilirubin.

　　The prevention principles of extrahepatic bile duct stones include three points: Reasonably adjust the dietary structure; actively prevent and treat infections; early detection and early treatment.

　　1. Develop the habit of drinking plenty of water: Drinking plenty of water can dilute urine, reduce the concentration of crystals in urine, flush the urinary tract, and is beneficial for preventing stone formation and promoting the excretion of stones. Generally, adults should drink more than 2000 milliliters of water per day, which is of certain significance for preventing stones.

　　2. Remove urinary tract obstruction factors: Actively treat urethral stricture, benign prostatic hyperplasia, and other factors to relieve urinary tract obstruction.

　　3. Aggressive treatment of urinary tract infections.

　　4. For long-term bedridden patients, encourage and help them to be more active, thereby reducing bone demineralization and improving urine flow.

　　5. Adjusting the acid-base degree of urine: Adjust the acid-base degree of urine according to the composition of the urinary stones, which can prevent the recurrence of urinary stones. For example, uric acid and oxalate stones are formed in acidic urine, while phosphate and carbonate stones are formed in alkaline urine.

　　6. Prevent and treat metabolic diseases, such as hyperthyroidism patients should undergo surgical treatment.

　　7. Dietary adjustment and drug prevention.

　　Ultrasound examination can detect stones in the bile duct and imaging of bile duct dilatation. B-ultrasound is generally the first choice, and ERCP or PTC can be added if necessary. CT is usually considered only when the results of the above examinations are questionable or unsuccessful.

　　1. Laboratory examination: elevated serum bilirubin, increased bilirubin in urine, decreased or absent urobilinogen in urine, and decreased urobilinogen in feces.

　　2. B-ultrasound shows bile duct dilatation and imaging of stones in the bile duct.

　　3. Ultrasound and CT show stones in the common bile duct or common hepatic duct, and liver function tests show an increase in direct bilirubin.

　　4. Physical examination shows tenderness under the xiphoid process and in the upper right abdomen, percussion tenderness in the liver area. Sometimes, an enlarged gallbladder can be palpated.

　　The diet for patients with extrahepatic bile duct stones should follow the principles of high sugar, high protein, high fiber, and low fat, and consume more fish, lean meat, fresh vegetables, and fruits. People with intrahepatic bile duct stones should quit smoking and limit alcohol intake, avoid overeating or consuming刺激性 food, as improper diet is often a direct cause of the disease. In addition, maintaining a good mental state and cultivating good habits are also effective measures for preventing and treating the disease.

　　1. Try to reduce the intake of fats, especially animal fats, do not eat fatty meat and fried food, and as much as possible replace animal oil with vegetable oil.

　　2. A considerable number of gallbladder inflammation and cholelithiasis are indeed related to the high content of cholesterol in the body and metabolic disorders, so it is necessary to limit the consumption of high-cholesterol foods such as fish roe, yolks of various eggs, and livers, kidneys, hearts, and brains of various carnivorous animals.

　　3. The best way to cook food is steaming, boiling, stewing, and braising, and it is strictly forbidden to eat a large amount of fried, baked, roasted, smoked, and pickled food.

　　4. Increase the intake of foods rich in high-quality protein and carbohydrates such as fish, lean meat, dairy products, fresh vegetables, and fruits to ensure heat supply and promote the formation of glycogen, protecting the liver.

　　5. Eat more foods rich in vitamin A such as tomatoes, corn, carrots, etc., to maintain the integrity of gallbladder epithelial cells, prevent the shedding of epithelial cells to form the core of stones, thereby causing stones or increasing the size and number of stones.

　　The main surgical treatment is used for extrahepatic bile duct stones, the principle is:

　　1. Try to remove as many stones as possible during surgery.

　　2. Remove the infected lesions.

　　3. Ensure the patency of the bile duct after surgery.

　　The surgical method adopts choledochoscopy, stone extraction and drainage, and if there is cholecystolithiasis and cholecystitis, cholecystectomy can be performed simultaneously if the condition permits. Common situations include three types: both ends are unobstructed, without other lesions, and T-tube drainage can be placed; the upper end is unobstructed, but the lower end has inflammatory stenosis and other obstructive lesions. If it is not possible to remove the obstruction surgically, biliary-enteric internal drainage can be used, and the commonly used biliary-enteric Roux-en-Y anastomosis is often used. If the patient is old and weak, and the condition is severe, choledochoduodenal anastomosis can also be performed; if the lower end is unobstructed but the upper end has obstructive factors, it is often intrahepatic bile duct stones, and they should be treated as intrahepatic bile duct stones. If sandy-like bile duct stones are found inside the bile duct, with bile duct dilation, bile-enteric anastomosis can also be performed during the first bile duct stone extraction. Before the operation, it is necessary to correct the imbalance of water, electrolytes, and acid-base balance, use effective antibiotics to control infection, strengthen the protection of liver function, pay attention to the overall nutrition and water, electrolyte, and acid-base balance after the operation, use antibiotics reasonably, and prevent and treat various complications.