Bile duct stones

　　Pathologically, bile duct stones are composed of cholesterol, bile pigments, and calcium salts of different composition. According to the different composition of bile duct stones, they can also be divided into cholesterol stones, which are mostly solitary, round, and large, with a smooth surface that can be granular, with a radiating section and can be X-ray penetrable. Bile pigment stones are mostly multiple, small, and without a certain shape. If it is a mixed stone, the center is often cholesterol (the remnants or eggs of parasites can also form the core), forming a concentric layered structure, which can be solitary or multiple, and large stones are mostly located in the gallbladder. Stones located in the bile duct are usually smaller and can cause obstruction, leading to bile duct dilation or even infection. Gallbladder stones often accompany cholecystitis.

　　1, Acute suppurative cholangitis is the most common complication of primary bile duct stones. The clinical manifestations of primary bile duct stones are mostly related to it. The main manifestations are right upper quadrant pain, chills, high fever, and jaundice. The common bacteria causing biliary infection are Gram-negative bacilli or anaerobic bacteria, with Escherichia coli being the most common, and mixed infections are more common. Acute suppurative cholangitis occurs when stones are lodged at the lower end of the bile duct. After treatment with anti-inflammatory and antispasmodic therapy, local inflammation and edema subside, stones float, lodging is relieved, and the above symptoms and signs disappear, resulting in fluctuating jaundice. Ultrasound can detect biliary dilatation or bile duct stones inside and outside the liver; there may be an increase in white blood cells and other laboratory findings. It is generally believed that acute suppurative cholangitis should first be treated with anti-inflammatory, antispasmodic, biliary, and fluid replacement therapy, and elective surgery should be performed after symptoms are relieved. However, in the process of non-surgical treatment, close observation should be made, and surgery should be considered if acute obstructive suppurative cholangitis occurs.

　　2, Cholestatic liver abscess is caused by purulent cholangitis due to the failure to perform timely surgical drainage of the biliary tract due to concurrent infection of bile duct stones or the occlusion of small intraportal bile duct stones. The inflammation spreads to surrounding tissues and forms abscesses. Multiple small abscesses are common. There may be right upper quadrant pain, or there may be no pain, presenting with chills and high fever, a remittent fever type, jaundice may or may not be present, and the course of the disease is generally long. This disease has not been effective after short-term non-surgical treatment, and biliary tract drainage should be performed. If it is a diffuse small abscess, biliary tract drainage alone is sufficient. If there is a single large abscess or multiple abscesses with larger abscesses, in addition to biliary tract drainage, the abscess should also be drained.

　　3, Biliary hemorrhage is a relatively serious complication of primary bile duct stones.

　　4, Cholestatic liver cirrhosis is an advanced complication of primary bile duct stones, which belongs to advanced chole duct diseases. In severe cases, it is accompanied by portal hypertension, splenomegaly, and hyperfunction of the spleen. In addition to the symptoms of bile duct stones, it also shows the manifestations of liver cirrhosis and portal hypertension. If the patient does not have portal hypertension, it is recommended to perform biliary exploration surgery as soon as possible to remove the intraportal stones as cleanly as possible, and some patients may hope to recover liver function. If portal hypertension is present, the treatment is more complex and difficult. If the patient's condition allows, a primary biliary exploration, stone removal, and splenectomy surgery can be performed, followed by a thorough operation on the bile duct stones to treat the complex intraportal lesions. Otherwise, staged surgery should be performed, starting with biliary exploration and stone removal, followed by portal hypertension surgery, and finally dealing with the complex bile duct surgery. These patients have severe conditions, difficult treatment, high mortality, and sometimes no matter how surgery is performed, the prognosis is extremely poor. Therefore, it is best to perform surgery for bile duct stones as soon as symptoms appear or just after symptoms appear to reduce liver function damage.

　　5. Most scholars believe that the occurrence of bile duct cancer is related to primary biliary stones. Especially, the occurrence of intrahepatic bile duct cancer is more common in patients with infected intrahepatic bile duct stones, also known as cholangiocellular liver cancer. It is often masked by the symptoms of primary biliary stones and is easily missed before surgery. Patients with primary biliary stones recently have frequent and severe upper abdominal pain localized to a certain area. Physical examination shows marked tenderness in the right upper quadrant or below the xiphoid process, and palpable masses with tenderness can be felt, suggesting this disease. Further ultrasound and CT examinations can simultaneously detect intrahepatic stones and focal or diffuse space-occupying lesions in the liver, which can basically clarify the diagnosis. For these patients, AFP is usually negative. Due to the repeated inflammation, fibrosis, and hyperplasia caused by biliary tract stones, cholangiocellular liver cancer is mostly hard cancer with a large amount of fibrous connective tissue. It mainly grows locally and has less liver metastasis and distant metastasis.

　　6. Primary biliary stones combined with acute pancreatitis is much less common than secondary biliary stones, which may be related to the fact that most patients with primary biliary stones have a relaxed state of the Oddi sphincter.

　　Clinically, it is more common in middle-aged women, mainly manifested as right upper quadrant colic pain, which is caused by the movement of gallstones in the biliary tract, causing the smooth muscle of the gallbladder or common bile duct to dilate and spasm, resulting in colic pain. Colic pain often has certain triggers such as overeating or abdominal vibration. The colic pain is usually a persistent and gradually worsening pain in the upper abdomen or right upper quadrant, often radiating to the right scapula or shoulder, and often accompanied by vomiting. Colic pain can occur intermittently. If the gallstone is impacted in the cystic duct, it can cause the gallbladder to dilate; if the gallstone is located at the opening of the common bile duct or the ampulla of the common bile duct, it can cause obstructive jaundice. The clinical symptoms of intrahepatic bile duct stones are relatively mild, mainly recurrent abdominal pain, chills, and fever, with occasional jaundice.

　　I. Stone prevention

　　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 the formation of stones and promoting the excretion of stones. Generally, adults should drink more than 2000 milliliters of water or magnetized water per day, which has certain significance for preventing stones.

　　2. Remove factors causing urinary tract obstruction

　　Actively deal with urethral stricture, benign prostatic hyperplasia, and other conditions to relieve urinary tract obstruction.

　　3. Actively treat urinary tract infections

　　4. Long-term bedridden patients should be encouraged and assisted to be more active in order to reduce bone demineralization and improve the flow of urine.

　　5. Adjust the acidity and alkalinity of urine

　　Adjusting the acidity and alkalinity of urine according to the composition of the stones can prevent the recurrence of urinary stones, such as uric acid and oxalate stones forming in acidic urine, and phosphate and carbonate stones forming in alkaline urine.

　　6. Prevent and treat metabolic diseases, such as for those with hyperthyroidism, surgical treatment should be performed.

　　2. Diet adjustment and drug prevention

　　1. Adjust diet according to the composition of the stones, such as for patients with oxalate stones, it is advisable to eat less food rich in oxalates, such as potatoes and spinach, and to take oral vitamin B6 to reduce the excretion of oxalates in urine, and to take magnesium oxide to increase the solubility of oxalates in urine. For patients with phosphate stones, a low-phosphorus and low-calcium diet is recommended, and oral ammonium chloride can acidify urine, which is beneficial for the dissolution of phosphates. For patients with uric acid stones, it is not advisable to eat foods rich in purines, such as liver, kidney, and legumes, and to take citrus acid mixture or sodium bicarbonate to alkalinize urine, keeping the urine pH above 6.5.

　　Experts point out that due to the complex etiology of urinary tract stones, the high incidence rate and the ease of recurrence after treatment remain one of the challenging problems currently faced in clinical practice. Therefore, when taking preventive measures, it is best to consider the specific causes that may be present in individual patients and tailor preventive measures accordingly.

　　2. Urolithiasis includes kidney stones, ureteral stones, bladder stones, and urethral stones, etc., and symptoms during an attack mainly include severe pain in the lower back and abdomen, vomiting, nausea, and other symptoms. To prevent urolithiasis and reduce the occurrence of stone pain, one should drink more water, eat less food high in salt, sugar, and calcium, and also exercise more. If drinking water is insufficient, urine can become overly concentrated, causing urine salts to precipitate and increasing the chance of stone formation. Drinking more water can increase urine volume, flush and clean the urinary tract, and in the case of urinary tract infection, drinking more water can also enhance drainage, which is beneficial for controlling infection and reducing the formation of infected stones. Therefore, it is important to drink more water in summer, at least ensuring to drink 1-2 catties of water per day.

　　3. It is also best not to drink beer and other beverages with high hardness when thirsty. At the same time, do not stay in air-conditioned rooms for a long time to avoid dry air and the loss of a large amount of body fluids. People who work in high-temperature environments should pay more attention to increasing water intake to compensate for the water lost through sweating. It is important to develop a drinking habit, actively drink more water, and not wait until thirsty to drink water.

　　4. In terms of diet, eat less animal internal organs, spinach, tofu, chili, nuts, salted fish, salted meat, and salted products. In addition, eat more low-calcium foods and less dairy products, as dairy products contain more calcium. Eat less sugar, as sugar intake can increase the concentration of calcium ions in urine, oxalic acid, and the acidity of urine, thereby increasing the chance of stone formation.

　　1. Film manifestation

　　About 20% of biliary calculi are not X-ray penetrable, so it is common to see single or multiple high-density shadows in the biliary tract area (gallbladder area) in abdominal flat films or lower right upper quadrant films, which can be large or small, with various shapes, such as concentric layered circles, irregularly clustered shapes, or shapes of several polyhedrons. The presence of these signs usually allows for the diagnosis of biliary calculi.

　　About 80% of biliary tract stones are X-ray penetrable, and generally nothing is found on the plain film.

　　2. Intra-venous biliary tract contrast imaging

　　It is mainly to understand the condition of the biliary tract, the function of the gallbladder, and whether there are stones. Negative stones are displayed as circular or square light shadows in the imaged bile ducts, especially in the gallbladder filled with contrast agent, which are more typical. These signs can be single or multiple, and sand grain stones in the gallbladder are displayed as granular negative light shadows in the imaged gallbladder.

　　3. ERCP

　　It can display X-ray-penetrable negative stones, understand the location of the stones in the intrahepatic or extrahepatic bile duct, whether the bile duct is completely obstructed by stones, and whether there is expansion of the intrahepatic and extrahepatic bile ducts and the extent of expansion.

　　4. Ultrasound manifestations

　　High-echo sound clusters in the gallbladder or bile duct, accompanied by an acoustic shadow.

　　5. CT manifestations

　　Due to the high resolution of CT in tissue density, it can make an accurate diagnosis of biliary tract stones, whether they are intrahepatic or extrahepatic stones. In CT examination, most biliary tract stones are displayed as high-density uniform or non-uniform shadows, which are easy to identify. Gallbladder stones can move when the body position changes.

　　6. MRI and MRCP examination

　　It is a non-invasive biliary tract imaging technique that can display low signal intensity stones within the biliary tract system.

　　1. 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 calorie supply and promote the formation of glycogen in the liver, thereby protecting the liver. Eat more foods rich in vitamin A, such as tomatoes, corn, and carrots, to maintain the integrity of gallbladder epithelial cells and prevent the shedding of epithelial cells to form the core of stones, which may trigger the formation of stones or increase the size and number of stones. Cook food mainly by steaming, boiling, stewing, and braising, and avoid eating large amounts of fried, baked, grilled, smoked, or pickled foods.

　　2. Minimize the intake of fats, especially animal fats, and avoid eating fatty meats and fried foods. As much as possible, replace animal oil with vegetable oil. A considerable number of gallbladder inflammation and gallstone formation are related to excessively high cholesterol levels and metabolic disorders in the body. Therefore, it is necessary to limit the intake of high-cholesterol foods such as the yolks of various eggs, the livers, kidneys, hearts, and brains of various carnivorous animals. Drink fresh vegetables or fruit juices, such as watermelon juice, orange juice, and carrot juice, and increase water intake, the frequency and quantity of meals, to enhance the secretion and excretion of bile, alleviate inflammation and bile stasis. Eat less food rich in fiber, such as garlic and celery, to avoid increasing gastrointestinal motility due to difficulty in digestion, which may trigger biliary colic. Quit smoking and drinking, and eat less spicy and刺激性 foods, such as strong seasonings like mustard oil, to avoid stimulating the gastrointestinal tract and exacerbating the condition. It is advisable to consume light, easily digestible, low-fiber, temperature-appropriate, non-irritating, and low-fat liquid or semi-liquid foods. One should never indulge in eating and drinking for the sake of temporary pleasure, as this may cause unnecessary trouble, and even trigger biliary bleeding that could be life-threatening.

　　Single incision laparoscopic cholecystectomy is a very common method in the treatment of biliary calculi. Patients who need cholecystectomy now prefer laparoscopic cholecystectomy. Patients with gallbladder polyps, chronic cholecystitis with gallstones, and benign gallbladder tumors are more suitable, but patients with full gallstones, atrophic cholecystitis, and severe adhesions around unclear gallbladder structure are not suitable for single incision laparoscopic surgery, and some patients may even need traditional laparotomy. Currently, at the beginning of the operation, the surgeon will first explore the inside through the umbilical incision with a laparoscope. This is only done for patients with clear gallbladder anatomy and no obvious adhesions, ensuring both surgical safety and increasing the success rate of the surgery.

　　The greatest advantage of choosing transumbilical single incision laparoscopic surgery for the treatment of biliary calculi is that there are no obvious surgical scars on the surface, which has a satisfactory cosmetic effect, especially favored by a large number of female patients. Secondly, it can alleviate postoperative pain and shorten the recovery time and hospital stay. Some patients with gallstones often have stones falling into the common bile duct, which was previously a contraindication for laparoscopy. However, with the mature application of minimally invasive technology, bile duct stones can also be solved without laparotomy. Currently, minimally invasive treatment can remove stones through laparoscopy or through duodenoscopy. Laparoscopic surgery can simultaneously remove the gallbladder and incise the bile duct to remove stones, which has small trauma, fast recovery, mild postoperative pain, safe surgery, and few complications. However, it requires high technical standards and a solid laparoscopic technique. The situation of bile duct stones is relatively complex, and the technical requirements for stone removal during surgery are high. Comprehensive examinations such as B-ultrasound and MRCP should be performed before surgery to have a full understanding of the patient's biliary anatomical structure. For patients with acute cholangitis, impacted bile duct stones, and very thin bile ducts, it is necessary to first perform stone removal through duodenoscopy, and then perform laparoscopic cholecystectomy about two weeks later. Minimally invasive treatment for biliary calculi significantly reduces trauma, shortens hospital stay, and is the future development direction of hepatobiliary surgery.