Gallstone disease

　　The cause of gallstone formation has not been fully clarified to date, and it may be a comprehensive factor. The composition of gallstones includes cholesterol, bile pigments, calcium salts, mucoprotein, and other organic and inorganic substances. Depending on the composition of the stones, gallstones are usually divided into three categories: cholesterol stones, bile pigment stones, and mixed stones (mixed with cholesterol, bile pigments, calcium, and other organic and inorganic substances). Over the years, research has proven that gallstones are formed under the influence of various factors through a series of pathological and physiological processes. These factors include changes in bile composition, supersaturated bile or cholesterol in a supersaturated state, precipitation of bile vesicles and cholesterol monocrystals, imbalance between promoting and inhibiting nucleation factors, abnormal gallbladder function, participation of oxygen free radicals, and biliary bacterial and parasitic infections.

　　The mechanism of gallstone formation The basic factors of gallstone formation include: changes in the physicochemical state of bile, bile stasis, and infection, among others. It is often caused by a combination of two or more factors. Changes in the physicochemical properties of bile cause the precipitation of bile pigments or cholesterol, forming stones; bile stasis can cause excessive absorption of water in bile, leading to overconcentration of bile, increasing the concentration of bile pigments, and cholesterol supersaturation, all of which can promote gallstone formation; bacterial infection can cause inflammatory edema, cell infiltration, and fibrous proliferation in the chronic stage, leading to thickening, narrowing, or even obstruction of the biliary wall, thus causing bile stasis. The exudate of cells or desquamated epithelium, bacterial colonies, remnants of ascaris, and eggs can also act as the core of stones, promoting gallstone formation.

　　The most serious complications of cholelithiasis are different degrees of acute cholecystitis, including gangrenous, emphysematous cholecystitis, pericholecystic abscess, and perforation. Chronic calculous cholecystitis is also a common complication of cholecystolithiasis. In addition to chronic cholecystitis (almost every patient with cholecystolithiasis has chronic cholecystitis), about 20% of patients with cholecystolithiasis may develop complications, and the incidence of complications increases significantly with age.

　　Generally speaking, when gallstones occur at different parts of the bile duct, their symptoms are not completely the same. The clinical manifestations are described according to cholecystolithiasis.

　　1. Cholecystalgia or upper abdominal pain:Cholecystalgia is an internal pain, mostly caused by temporary obstruction of the cystic duct by gallstones. If there is concurrent acute inflammation of the gallbladder, the gallbladder wall may show varying degrees of congestion, edema, or thickening, and in typical cases, patients often have recurrent upper abdominal pain, usually located in the upper right abdomen or upper abdomen, with severe cases presenting as colic pain, which may worsen after eating; in some cases, pain may occur at night, and colic attacks often occur in individuals with little physical activity or exercise (such as those who have been bedridden for a long time), with typical attacks of cholecystalgia usually becoming gradually more severe within 15 minutes or 1 hour, and then gradually less severe; about 1/3 of patients may have sudden onset of pain, and a few patients may have their pain suddenly stop. If the pain persists for 5 to 6 hours or more, it often indicates the presence of acute cholecystitis. More than half of the patients may have pain that radiates to the right scapular area, the central back, or the right shoulder, and during attacks of cholecystalgia, patients are often restless, sitting or lying down. The intervals between attacks may be days, weeks, months, or even years, and the timing of attacks is unpredictable, which is a characteristic of cholecystalgia.

　　2, Nausea and vomiting:Most patients have nausea and vomiting at the same time as biliary colic attacks, and some may have cold sweat. After vomiting, the biliary colic often decreases to a certain extent, and the duration of vomiting is generally not long.

　　3, Dyspepsia:Dyspepsia is manifested as intolerance to fat and other foods,表现为over-abdominal bloating, early satiety after meals, early satiety, heartburn, and other symptoms. The occurrence of dyspepsia may be related to the presence of gallstones or coexisting cholecystitis.

　　4, Chills and fever:When acute cholecystitis occurs, the patient may have chills and fever; when gallbladder hydrops secondary to bacterial infection forms gallbladder empyema or gangrene, perforation, then chills and fever are more significant.

　　5, Jaundice:Simple gallstones do not cause jaundice. Jaundice may occur only when associated with common bile duct stones or inflammation (cholangitis), or when gallstones pass into the common bile duct and cause obstruction. Some patients may have pruritus.

　　6, Tenderness in the upper right abdomen:Some patients with simple gallstones may have tenderness in the upper right abdomen during physical examination. If acute cholecystitis occurs, there will be marked tenderness in the upper right abdomen, muscle tension, and sometimes an enlarged gallbladder can be palpated, and Murphy sign is positive.

　　7, Biliary heart syndrome:A clinical syndrome caused by reflexive dysfunction of cardiac function or changes in heart rhythm due to gallstones and other biliary tract diseases is called biliary heart syndrome. The coronary arteries or heart of the patient has no organic lesions. The mechanism by which cholelithiasis causes coronary heart disease-like symptoms is that when cholelithiasis, biliary tract obstruction, and intrabiliary pressure increase, they can cause vasoconstriction of coronary vessels, reduce blood flow, and in severe cases, can lead to myocardial ischemia and angina pectoris, arrhythmia, or changes in electrocardiogram.

　　The prevention of gallstones mainly includes the following two aspects:

　　The formation of gallstones is related to the over-saturation of cholesterol concentration in bile, therefore, controlling the excessive intake of cholesterol in the diet is an important means to maintain the stability of bile. In daily life, it is necessary to reasonably adjust the dietary structure, eat less fatty foods rich in cholesterol, and eat more high-protein foods, vegetables, and fresh fruits. Pregnant women should pay particular attention to this. In addition, appropriate physical exercise should be carried out in daily life to prevent excessive accumulation of fat in the body.

　　Every year, regular physical examinations should be conducted, including liver and gallbladder ultrasound examinations, to facilitate early detection and treatment.

　　Gallstone patients can be diagnosed based on their clinical history of typical colic pain and imaging examinations. Ultrasound examination is the first choice, and the presence of hyperechoic masses in the gallbladder that move with body position change and have an acoustic shadow can be diagnosed as gallstones. Only 10% to 15% of gallstones contain calcium, and abdominal X-rays can confirm the diagnosis, and the lateral view can be distinguished from renal calculi on the right side. CT and MRI can also show gallstones, but are not routine examinations.

　　Gallstone patients should eat more vitamin C and various fresh fruits, such as fresh oranges, as vitamin C can convert excess cholesterol in the body into bile acids, reducing the amount of bile that breaks down fat and neutralizing cholesterol, thereby reducing the chance of gallstones. They should also eat more foods rich in vitamin A, such as green vegetables, carrots, tomatoes, and cabbage, as vitamin A has a moisturizing and nutritional effect on epithelial cells and may also reduce the formation of cholesterol stones. They can eat more lean meat, chicken, fish, walnuts, black fungus, kelp, and seaweed, and cook with vegetable oil. The dishes they eat should be mainly stewed, braised, or steamed. They should eat low-fat, low-cholesterol foods such as enoki mushrooms, black fungus, celery, sprouts, kelp, fish, lotus root, rabbit meat, chicken, and fresh beans.

　　The goal of treating gallstones is to alleviate symptoms, reduce recurrence, eliminate stones, and prevent the occurrence of complications. During the acute attack, non-surgical treatment should be performed first, and further examination should be carried out after the symptoms are controlled to clarify the diagnosis; if the condition is severe and non-surgical treatment is ineffective, surgical treatment should be performed in a timely manner based on the preliminary diagnosis.

　　The main indications for non-surgical therapy are young patients with the first attack; those whose symptoms are rapidly relieved after non-surgical treatment; those with atypical clinical symptoms; those who have been ill for more than 3 days without urgent surgical indications, and whose symptoms have subsided under non-surgical treatment. Common non-surgical therapies include bed rest, dietary restriction or low-fat diet, intravenous fluid therapy, correction of electrolyte and acid-base imbalance, anti-infection, antispasmodic analgesics, and supportive treatment. In cases of shock, strengthen the treatment of shock, such as oxygen inhalation, maintenance of blood volume, and timely use of pressor drugs. After the above treatment, most cases can be relieved, and after 4-6 weeks after the acute phase, definitive biliary tract surgery can be performed to avoid the pain of repeated surgery.