Senile cholelithiasis

　　The formation of senile gallstones is not caused by a single pathological factor. Studies over the years have confirmed that gallstones are the ultimate result of a series of pathological and physiological processes influenced by multiple factors.

　　1. Abnormal metabolism of cholesterol, bile salts, and phospholipids
　　The main components of bile are bile salts, cholesterol, and phospholipid bilirubin, etc. The proportion of cholesterol, bile acids, and phospholipids in bile is crucial for maintaining the solubility of cholesterol. When the secretion of cholesterol increases and the secretion of bile salts decreases, these three abnormalities can occur individually or together, leading to an increase in the secretion of lithogenic bile. All of them can cause cholesterol to become supersaturated. In 1954, Isaksson and others proposed that colloidal particles formed by bile salts and lecithin maintain the solubility of cholesterol in bile. However, it was recently discovered that there is also a cholesterol carrier and phospholipid vesicles, which are mainly composed of phospholipids and cholesterol and exist in all bile. Usually, the molar ratio of cholesterol to phospholipids within the vesicles can reach 5:2, while in microsomes, the ratio is 1:2 to 1:5. Vesicles can carry more cholesterol than microsomes. When the ratio of cholesterol to phospholipids increases, such as 3:2 in vesicles and 1:3 in microsomes, it exceeds the carrying capacity and reaches the sub-stable state limit concentration, leading to the precipitation of cholesterol.

　　2. Disruption of the balance between nucleation and antinucleation factors
　　The first step in the formation of stones is nucleation, which is the polymerization of cholesterol molecules into a relatively large solid mass. Once this mass and the core are formed, cholesterol crystal growth can occur, followed by more molecules沉积ing in the cracks of the crystals, forming stones. This hypothesis has been recognized and agreed upon by most scholars. In addition, some scholars believe that both normal people and gallstone patients have nucleation factors and nucleation inhibitors in their bile. Whether nucleation occurs depends on the proportion between the two. If the proportion is out of balance and the nucleation factor is dominant, nucleation can be promoted, otherwise, it cannot occur. The nucleation time in normal bile is long, while the nucleation time in bile of gallstone patients is short, indicating the presence of factors for cholesterol precipitation in bile. On the other hand, in the experimental model system, cholesterol precipitation is much faster than that in bile containing the same lipid components, indicating the presence of antinucleation factors in bile.

　　3. Abnormal function of the gallbladder
　　The gallbladder has the functions of concentration, storage, and excretion of bile. If these functions are abnormal, they can also promote the formation of gallstones, especially the formation of cholesterol gallstones in the gallbladder is closely related to gallbladder dysfunction. The normal gallbladder mucosa has the function of secreting H+ water and electrolytes, which can acidify bile, reduce the pH value of bile, reduce the precipitation of calcium ions in the gallbladder, dilute bile, and accelerate the excretion of gallbladder sludge. When bile is concentrated in the gallbladder, increasing viscosity, and the reduction of bile emptying during fasting, mechanical and inflammatory stimulation lead to bile stasis, and weaken the above-mentioned functions, which can lead to the formation of gallstones. In addition, when the contraction function of the gallbladder is reduced and the emptying dysfunction of the gallbladder is present, it is conducive to the formation of gallstones in the gallbladder.

　　4. Increase in the content of unconjugated bilirubin in bile
　　The bile acid hydrolase produced by the infection in the bile and bile ducts of mammals can hydrolyze conjugated bilirubin into unconjugated bilirubin. Unconjugated bilirubin can combine with calcium ions to form bilirubin and precipitate, and the precipitation aggregates to form calcium bilirubinate stones. The formation of bilirubin calcium is closely related to bile duct infection, bacterial or parasitic infection, eggs, and residual sutures. The inflammatory desquamation of epithelium, bacteria, ascaris bodies, and eggs often constitute the core of gallstones. Especially, the bile duct ascaris is the main cause of gallstone disease in China. In addition, due to excessive destruction of red blood cells, chronic hemolytic anemia and liver cirrhosis can cause an increase in the content of unconjugated bilirubin in bile, which is prone to form melanotic stones.

　　5. Other
　　The formation of gallstones is also related to gender, environment, soil, dietary habits, family, race, genetic factors, etc.

　　The most serious complications of senile gallstone disease are different degrees of acute cholecystitis, including gangrenous, emphysematous cholecystitis, pericholecystic abscess, and perforation, etc. Chronic calculous cholecystitis is also a common complication of gallstones. In addition to chronic cholecystitis (almost every patient with gallstones has chronic cholecystitis), about 20% of patients with gallstones may have complications, and the incidence of complications increases significantly with age.
　　The common complications of common bile duct stones include varying degrees of cholangitis and bacterial infection of the bile ducts. Secondly, there are cholelithiasis pancreatitis, liver abscess, sepsis, biliary-enteric fistula, and cholelithiasis intestinal obstruction, etc. It is rare for bile duct stenosis to be caused by the compression of gallstones leading to mucosal ulcers in the common bile duct. In China, it is sometimes seen that gallstones cause mucosal ulcers, necrosis, and hemorrhage in the bile ducts, while in Western countries, it is rare for patients with common bile duct stones to have biliary hemorrhage. In addition, patients with common bile duct stones that cause long-term recurrent cholangitis and jaundice may further develop into biliary cirrhosis.

　　Generally speaking, when gallstones occur at different sites in the biliary tract, their symptoms are not completely the same. Now, the clinical manifestations are described separately for gallstones in the gallbladder, extrahepatic bile duct stones, and intraphepatic bile duct stones.
　　1. Clinical manifestations of gallstone disease
　　1. Cholecystalgia or upper abdominal pain
　　Cholecystalgia is an visceral 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. In typical cases, patients often have recurrent episodes of upper abdominal pain, usually located in the upper right abdomen or upper abdomen, with severe cases presenting as colic, which may worsen with eating; in some cases, pain may occur at night. The onset of colic attacks often occurs in individuals with insufficient physical activity or exercise (such as those who have been bedridden for a long time). The typical attack of cholecystalgia usually presents with a gradual increase in pain within 15 minutes or 1 hour, followed by a gradual decrease; about 1/3 of patients may experience a sudden onset of pain, and a few patients may experience a sudden termination of pain. 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 radiating to the right scapular area, the central back, or the right shoulder. During an attack of cholecystalgia, patients often feel restless, sitting or lying down. The interval between attacks may be several days, weeks, months, or even years, and the timing of the 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 in severe cases, accompanied by cold sweat. After vomiting, the biliary colic usually decreases to some extent. The duration of vomiting is generally not very long.
　　3. Dyspepsia
　　Dyspepsia is manifested as intolerance to fat and other foods, often manifested as excessive belching or abdominal distension, fullness 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 complicated by acute cholecystitis, patients may have chills and fever; when cholecystitis积水secondary to bacterial infection forms empyema or gangrene, perforation, chills and fever are more pronounced.
　　5. Jaundice
　　Simple gallbladder stones do not cause jaundice. Jaundice may occur only when accompanied by common bile duct stones or inflammation (cholangitis), or when gallbladder stones are expelled into the common bile duct and cause obstruction. Some patients may have pruritus.
　　6. Tenderness in the right upper quadrant
　　In some patients with simple gallbladder stones, tenderness may be present in the right upper quadrant during physical examination. If complicated by acute cholecystitis, marked tenderness in the right upper quadrant, muscle tension, and sometimes palpable enlargement of the gallbladder, a positive Murphy sign, may occur.
　　7. Biliary heart syndrome
　　A group of clinical symptoms caused by reflexive changes in cardiac function or rhythm due to gallbladder stones or other biliary tract diseases, without organic lesions in the coronary arteries or heart, is called biliary heart syndrome. The mechanism by which gallstone disease causes symptoms similar to coronary heart disease is that when gallstone disease, bile duct obstruction, and increased intrabiliary pressure occur, they can cause vasoconstriction and reduced blood flow through the spinal nerve reflex (支配胆囊与心脏的脊神经在胸4～5脊神经处交叉), that is, through the visceral-visceral nerve reflex pathway, leading to coronary vessel constriction, reduced blood flow, and in severe cases, myocardial hypoxia, resulting in angina, arrhythmia, or changes in electrocardiogram.
　　2. Clinical manifestations of extrahepatic bile duct stones
　　Extrahepatic bile duct stones refer to stones occurring in the common bile duct and bile duct, with common bile duct stones being the most common. About 15% of patients with gallbladder stones may coexist with common bile duct stones, and the proportion of coexistence increases with age. Conversely, about 95% of patients with common bile duct stones coexist with gallbladder stones. The stones in patients with common bile duct stones are mostly located at the lower end of the common bile duct and the ampulla of the duodenum. When bile stones cause obstruction of the common bile duct, typical symptoms and signs may occur. The clinical manifestations are closely related to factors such as bile duct obstruction, increased intrabiliary pressure, impaired bile excretion, and concurrent bacterial infection. Typical symptoms include biliary colic, chills, high fever, and jaundice, known as the triad of common bile duct stones, i.e., Charcot's triad.
　　1. Upper abdominal pain or colic
　　More than 90% of patients with common bile duct stones have pain or colic in the upper abdomen or right upper quadrant, which may radiate to the right shoulder and back. The cause of colic is due to the impaction of stones in the ampulla of the lower end of the common bile duct, leading to obstruction of the common bile duct and stimulation of the Oddi sphincter and bile duct smooth muscle. Colic can be induced after eating greasy food, or after changes in body position or being jostled. Severe cases may be accompanied by symptoms such as cold sweat, pale complexion, nausea, and vomiting.
　　2. Chills and high fever
　　About 75% of patients with common bile duct stones may experience chills and high fever after an attack of biliary colic due to concurrent cholangitis, with body temperature up to 40°C. The cause of chills and high fever is the backward spread of infection into the liver, with bacteria and their toxins passing through the hepatic sinusoids, hepatic veins to the systemic circulation, leading to systemic infection. A few patients with common bile duct stones, if acute bile duct obstruction occurs at the same time with severe cholangitis, leading to acute suppurative inflammation, it is called acute suppurative cholangitis or severe acute cholangitis, which may appear with hypotension, toxic shock, and sepsis and other systemic toxic clinical manifestations.
　　3. Jaundice
　　About 70% of patients with common bile duct stones may appear jaundice within 12 to 24 hours after abdominal绞痛, chills, and high fever. The mechanism of jaundice is due to the fact that the stone is lodged in the ampulla of Vater and cannot be loosened, leading to obstruction of the common bile duct and failure to relieve obstruction, often accompanied by skin itching, urine darkens to tea color, and feces become pale or clay-colored. Most patients' jaundice may be fluctuating, and it may be relieved in about a week, which is due to the relaxation of the bile duct after expansion or due to the fact that the stone has been excreted into the duodenum through the relaxed sphincter. Some scholars believe that the intermittent appearance or fluctuating depth of jaundice is a characteristic of common bile duct stones.
　　4. Pain in the upper abdomen
　　During physical examination, there is deep tenderness under the xiphoid process and in the upper right abdomen, and in severe inflammation, the abdominal muscles are often tense, and there may be percussion tenderness in the liver area. If the cystic duct is patent, sometimes an enlarged gallbladder can also be palpated.
　　3. Clinical manifestations of intrahilar bile duct stones
　　Stones originating from above the bifurcation of the left and right hepatic ducts are called intrahilar bile duct stones. The stones can be widely distributed in the intrahilar bile duct system, scattered in a branch of the intrahilar bile duct, or occur in the bile ducts of a certain lobe or segment of the liver. A large amount of data shows that stones occurring in the left intrahilar bile duct are more common. The main clinical manifestations include:
　　1. Pain in the upper abdomen
　　The symptoms of intrahilar bile duct stones are often atypical. Small stones scattered in the intrahilar bile ducts usually do not cause symptoms, or only manifest as persistent dull pain or distension in the upper right abdomen and back. Generally, colic does not occur.
　　2. Jaundice
　　General intrahilar bile duct stones do not cause jaundice, but jaundice may appear only when both or both left and right bile ducts are blocked by stones, at this time, most patients may also have biliary colic or more severe pain. If cholangitis occurs, chills and high fever may also appear, and in severe cases, it may develop into acute suppurative cholangitis.
　　3. Pain in the upper abdomen
　　During physical examination, it is often possible to palpate an enlarged liver with tenderness, and a few may have pain on liver area percussion. Most data show that intrahilar bile duct stones often coexist with common bile duct stones, so when patients have typical symptoms of cholelithiasis (colic, chills and high fever, jaundice), it is often the symptom of common bile duct stones.

　　The elderly have weaker physical constitutions, lower digestive and metabolic efficiency, and are prone to gallstones. Prevention should not only pay attention to daily life but also avoid triggering factors of cholelithiasis from multiple aspects to prevent the occurrence of cholelithiasis.

　　Firstly, Tertiary Prevention

　　Due to the atypical nature and complexity of attacks in elderly cholelithiasis, disease prevention is extremely important and meaningful.

　　1. Primary Prevention (Etiological Prevention)

　　This refers to taking various measures to control or eliminate health risk factors. The main cause of cholesterol gallstones is the precipitation of cholesterol due to over-saturation. Therefore, the elderly should eat less of cholesterol-rich foods such as brain, liver, kidney, fish eggs, and egg yolks. In addition, it is important to actively emphasize outdoor activities such as exercises, running, and walking to promote cholesterol metabolism in the body. Moreover, it is also important to actively prevent the formation of nucleation factors, pay attention to personal hygiene, prevent the occurrence of intestinal parasites and intestinal infections, and actively prevent biliary tract infections.

　　2. Secondary Prevention (Clinical Prevention)

　　Early detection, early diagnosis, and early treatment should be done in the early stage of clinical diseases to allow for early cure or prevent exacerbation of the disease. Cholelithiasis generally has a chronic development process. 60% to 80% of patients with gallbladder stones are asymptomatic for a certain period of time. The speed at which asymptomatic patients develop symptomatic stones varies greatly from place to place, with approximately 2% of patients developing various symptoms each year in the first five years. Therefore, for high-risk areas and special populations such as obesity, women, the elderly, multiple pregnancies, and those with a family history of hereditary diseases, it is important to carry out mass screening, targeted screening, or regular health checks, adopt non-invasive and convenient examination methods, and early detection and diagnosis. Early treatment should be actively pursued, including diet control, dissolution of stones, deworming, anti-inflammatory, and promoting gallbladder contraction.

　　3. Tertiary Prevention (Clinical Prevention)

　　Timely and effective treatment measures should be taken for patients with diseases to prevent the deterioration of the disease, complications, and to promote recovery and extend life. Different treatment measures should be taken for patients with different conditions. When acute biliary tract infection is present, broad-spectrum antibiotics with high concentration and sensitivity in bile should be chosen. When pain is significant, fasting, gastroenteric decompression, and necessary analgesic and sedative measures should be provided. In necessary cases, surgical treatment and endoscopic stone removal can be performed to prevent the progression of the disease and the occurrence of life-threatening cardiovascular and cerebrovascular diseases and other systemic complications.

　　Secondly, Risk Factors and Intervention Measures

　　1. Factors Contributing to Diet

　　The formation of gallstones is related to a lack of fiber in the diet, which increases the content of bile acids such as deoxycholic acid in bile. Moreover, a high-cholesterol diet can also increase the content of cholesterol in the bile ducts. Hunger can reduce the excretion of bile, and the storage of bile can lead to the formation of gallstones. Therefore, it is important to have a balanced diet every day, adjust dietary structure, eat more vegetables, and reduce cholesterol intake.

　　2. Factors Contributing to Infection

　　Factors such as biliary tract infection, intestinal infection, parasitic eggs, and worm bodies can promote the formation of gallstones. Therefore, it is important to actively prevent infection and pay attention to personal and dietary hygiene.

　　3. Factors Contributing to Obesity

　　Obese individuals are more prone to cholelithiasis. Data shows that 50% of obviously obese patients have gallstones upon surgery, hence it is important to actively participate in physical exercise and control weight within the normal range.

　　4, Gender and reproductive factors

　　Females with gallstone disease are significantly more than males, multiparous women are more prone to stones than nulliparous women, and women taking oral contraceptives have a high incidence of stone disease. Therefore, family planning and birth control surgery should be promoted.

　　5, Age and genetic factors

　　The incidence of gallstone disease increases with age, and those with gallstone disease family members are more prone to gallstone disease.

　　6, Other disease factors

　　Patients with chronic hemolytic anemia, liver cirrhosis, and post-gastrectomy patients are also predisposing factors for gallstone disease, and the primary disease should be actively treated.

　　Third, community intervention

　　The implementation of community intervention programs must have a complete organizational system to ensure it, including government support in policy and strong assistance from community medical institutions. First, through health education, personnel training, and changing the environment, special intervention projects are carried out to reduce the population's risk factors. To make the elderly optimistic, have a good living environment, carry out various forms of health education, enjoy medical insurance and other welfare benefits, have a reasonable diet, and carry out physical exercise. On the other hand, through early diagnosis and treatment of gallstone disease patients, reduce the incidence rate, rational drug use, considering that the elderly have poor detoxification and excretion, and are prone to adverse reactions, strictly follow the doctor's orders and do not misuse or arbitrarily discontinue medication.

　　The symptoms of elderly gallstone disease are typical, and with the continuous development of medical examination methods in recent years, diagnosis is not difficult. The routine examinations for gallstone disease include the following aspects:
　　First, laboratory examination:When patients with gallstone disease have biliary obstruction and accompanying biliary infection, the metabolism of bilirubin, liver function, blood routine, and serological enzymes may be abnormal.
　　1, Bile pigment metabolism: During biliary obstruction, the serum total bilirubin increases, mainly due to the increase in conjugated bilirubin. The ratio of 1-minute bilirubin to total bilirubin is usually greater than 35%, and when the bile duct is completely obstructed, the ratio can be greater than 60%. Urinary bilirubin increases, while urinary bilirubinogen decreases or disappears. Faecal bilirubinogen decreases or disappears.
　　2, Abnormal serum enzymes: During obstruction, alkaline phosphatase is significantly increased, often more than three times the normal value. Gamma-glutamyl transpeptidase is also significantly increased. Serum transaminases show mild to moderate elevation, and lactate dehydrogenase is generally slightly increased.
　　3, Blood routine: When complicated with cholecystitis, there may be a slight increase in white blood cells and neutrophils. If it develops into acute suppurative necrotic cholecystitis or cholecystectomy, the white blood cells may increase to 20×10⁹/L above, neutrophils increase to above 0.90 and toxic granules appear. A few cases may develop into a leukemoid reaction, with white blood cells reaching 40×10⁹/L.
　　4, Prothrombin time measurement: In the case of biliary obstruction, the prothrombin time is prolonged. After the application of vitamin K, the prothrombin time can return to normal. If the biliary obstruction is long-term and causes severe liver dysfunction, even after injection of vitamin K, the prothrombin time does not return to normal, indicating that there is a disturbance in the liver cells in the production of prothrombin.
　　5. Serum iron and copper content determination The normal ratio of serum iron to serum copper is 0.8 to 1.0. During bile duct obstruction, an increase in serum copper often causes the iron/copper ratio to be less than 0.5.
　　6. Duodenal fluid drainage: The three parts of bile drained can not only be seen for inflammatory cells produced due to infection, but also cholesterol and calcium bilirubinate crystals and eggs, suggesting the possibility of the presence of gallstones. If there is no such finding, it does not support the diagnosis of cholelithiasis, or it may be the result of obstruction at the distal end of the common bile duct.
　　2. Other auxiliary examinations
　　1. Imaging examination: The imaging examination methods for cholelithiasis mainly include X-ray film, ultrasonography, X-ray computed tomography (CT), magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), intraoperative cholangiography, cholangioscopy, postoperative T-tube cholangiography, and the following are described according to their advantages and disadvantages:
　　(1) X-ray film: Simple cholesterol stones and bilirubin stones cannot be visualized on X-ray films, only mixed stones containing calcium can be visualized, so the accuracy rate for diagnosing gallbladder stones is only 50% to 60%. Oral cholecystography can increase the visualization rate to 80%. Since X-ray cholecystography cannot clearly visualize the bile duct, intravenous injection of methylene blue can be used for X-ray cholangiography. Cholangiography in cases after cholecystectomy is more valuable. However, in cases with obvious liver function damage or severe obstructive jaundice, intravenous cholangiography often cannot visualize.
　　(2) Ultrasonography: Ultrasonography has the advantages of being convenient, non-invasive, repeatable multiple times, and high diagnostic accuracy, and has become the first choice for diagnosing cholelithiasis. An A-mode ultrasonic instrument can measure whether the gallbladder or bile duct is dilated. B-ultrasound can well display intrahepatic and extrahepatic bile ducts, gallbladder dilatation, expansion, and the presence of stones. However, its accuracy is often affected by various factors such as gastrointestinal gas interference in patients, the examiner's experience, and the conditions of the B-ultrasound instrument.
　　(3) X-ray computed tomography (CT) and magnetic resonance imaging (MRI): The accuracy rate of CT in diagnosing stones is 80% to 90%, with high sensitivity to calcium-containing stones, often showing small stones with a diameter of 2mm. It is significantly superior to ultrasound in diagnosing the location and cause of bile duct obstruction. The imaging of cholelithiasis and bile duct obstruction diagnosed by MRI is basically the same as that by CT, but it can display soft tissue structures better than CT. However, due to the high cost of CT and MRI, they are usually only chosen when ultrasound cannot make a diagnosis.
　　(4) Endoscopic retrograde cholangiopancreatography (ERCP): This is a direct method of injecting contrast material into the gallbladder using a fiberoptic duodenoscope, which can clearly visualize the entire biliary tract and gallbladder, with a diagnostic accuracy for common bile duct stones of about 95%. If there is a stricture or obstruction in the bile duct, it can only display the image of the bile duct below the obstruction, while the bile duct above the obstruction is poorly visualized or not visualized at all.
　　(5) Percutaneous liver puncture cholangiography (PTC): PTC is an invasive examination that can clearly display the entire extrahepatic and intrahepatic bile duct system. It has important diagnostic value for the localization of gallbladder and extrahepatic bile duct stones, as well as for judging whether there is obstruction in the bile ducts.
　　(6) During surgery: Postoperative bile duct造影 and bile duct endoscopy. In gallbladder surgery, the contrast agent can be directly injected into the cystic duct or common bile duct, which can clearly show the intrahepatic and extrahepatic bile ducts. Before removing the T tube, retrograde contrast is performed to show whether there is stenosis, obstruction, and residual stones. Bile duct endoscopy refers to inserting a fiberoptic bile duct endoscope through the incision for exploration of the common bile duct during bile duct surgery to understand whether there are stones or other lesions at the lower end of the common bile duct, and to avoid blind examination that may damage the duodenum.
　　2. Radionuclide examination: After fasting for 2 to 14 hours, 99mTc-EHIDA or 99Tc-trimethyl bromoform (mebrofenin) is injected intravenously, followed by γ-photography for liver and gallbladder scintigraphy, which can display the liver, gallbladder, and bile ducts. When cholelithiasis is complicated with acute cholecystitis due to biliary duct obstruction, the gallbladder does not appear in 95% of patients, and cholecystitis can be ruled out.

　　The dietary precautions for senile cholelithiasis patients include the following aspects:

　　1. The calorie supply should meet the physiological needs, but prevent excessive intake, generally 1500 to 2400 calories.

　　2. Limit fat intake to avoid stimulating gallbladder contraction and relieve pain. The fat in the diet before and after surgery should be limited to about 20 grams, which can be slightly increased as the condition improves to improve the color, aroma, and taste of the dishes and stimulate appetite. Avoid greasy, fried, and high-fat foods such as lard, mutton, stuffed ducks, fat geese, butter, fried pastries, and cream cakes.

　　3. Control the intake of foods high in cholesterol to alleviate the metabolic disorder of cholesterol esterase and prevent the formation of stones.

　　4. Supplement protein. Sufficient protein can compensate for loss, maintain nitrogen balance, enhance the body's immunity, and is beneficial for repairing liver cell damage and restoring normal function. The daily protein supply should be 80 to 100 grams, and the food choices should include fish, shrimp, lean meat, rabbit meat, chicken, and tofu.

　　5. Supplement vitamins and inorganic salts. Choose foods rich in calcium, potassium, and iron. It is also important to supplement vitamin C and B vitamins as well as fat-soluble vitamins.

　　6. Increase the intake of fibrous vegetables and fruits, which can reduce the formation of gallstones.

　　7. Abstain from eating all spicy and strongly刺激性 foods and seasonings.

　　The treatment goal of senile cholelithiasis is to alleviate symptoms, reduce recurrence, eliminate stones, and prevent the occurrence of complications. During the acute attack phase, non-surgical treatment should be performed first, followed by further examination 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.

　　1. Treatment

　　1. General treatment

　　(1) Control diet: Fatty foods can increase gallbladder contraction due to the release of cholecystokinin, and if the Oddi's sphincter cannot relax in time to allow bile to flow out, it can increase discomfort. Therefore, in the acute phase, fatty foods should be avoided, and cholesterol-rich foods should be eaten in moderation during the attack or remission of cholelithiasis. In the absence of biliary tract obstruction or during the static phase of stones, vegetable oils have a choleretic effect and do not need to be restricted.

　　(2) Maintain a cheerful spirit and optimistic mood: because anger or depression often causes biliary colic.

　　(3) Pay attention to personal hygiene, prevent the occurrence of intestinal parasites and intestinal infections, and prevent the occurrence of biliary infections.

　　(4) Strengthen physical exercise, promote the metabolism of cholesterol in the body.

　　2. Litholysis treatment

　　(1) Oral litholysis: Commonly used oral litholytic drugs include chenodeoxycholic acid (CDCA) and ursodeoxycholic acid (UDCA), but chenodeoxycholic acid (CDCA) and ursodeoxycholic acid (UDCA) can only dissolve cholesterol stones, and are basically ineffective for calcium-containing stones and bilirubin stones. The litholysis effect is good for stones with a diameter of 5 to 10 mm. The optimal dose of chenodeoxycholic acid (CDCA) is 375 to 750 mg/d, and there are also those who use 750 to 1500 mg daily. The optimal dose of ursodeoxycholic acid (UDCA) is 150 to 450 mg daily, but due to the side effects of chenodeoxycholic acid (CDCA) such as diarrhea and increased transaminases, it is now rarely used, and if used, it is necessary to follow up on the transaminase situation. Ursodeoxycholic acid (UDCA) does not cause diarrhea or liver function damage. If ursodeoxycholic acid (UDCA) and chenodeoxycholic acid (CDCA) are used in combination, the adverse reactions are significantly reduced. However, the following conditions are not suitable for litholysis treatment: ①Bilirubin stones and calcium salt-containing stones. ②Stones with a diameter greater than 15 mm. ③Pregnant women. ④Complications with acute cholecystitis, biliary obstruction, acute cholangitis, and biliary pancreatitis. ⑤Oral cholecystography does not show up. ⑥Litholysis treatment has reached two years, and the stones are still dissolved, indicating that the treatment is ineffective, and treatment should be terminated.

　　(2) Contact Litholysis: Direct drug litholysis through percutaneous or transhepatic cholecystoduodenal tube. ①Drugs for dissolving cholesterol stones: Methylbutyl ether, which can be used when patients are not suitable for laparoscopic cholecystectomy or open surgery. The gallstones usually dissolve within 1 to 5 days of treatment, but this drug has a high toxicity, and accidental injection into the liver parenchyma can cause liver cell necrosis, intravascular hemolysis, and even acute renal failure. Monosodium laureth sulfate (monosodium laurel fat), adverse reactions to this drug occur in about 60% of patients, mainly including nausea, vomiting, diarrhea, fever, and elevated serum alkaline phosphatase, and a few cases may develop pancreatitis and cholangitis. ②Drugs for dissolving bilirubin stones: Dimethyl sulfoxide amine, an organic solvent, is non-toxic to the human body, and can produce a garlic-like odor in exhaled air after administration. Ethylenediamine tetraacetic acid disodium, the effect of this drug alone is not ideal, and it is often used in combination with other litholytic drugs.

　　3. Lithotripsy treatment

　　Extracorporeal shock wave lithotripsy uses shock waves generated by electrohydraulic, piezoelectric, or magnetoelectric to fragment gallbladder calculi. It is generally used for symptomatic calculi in the gallbladder with a diameter less than 20mm and a number not exceeding 2 to 3, with normal gallbladder function. Due to its non-invasive nature, less pain, and ease of acceptance by patients, it is easy to be accepted by patients.

　　Percutaneous and laparoscopic cholecystolithotomy: It has the advantages of minimal trauma, less pain, thorough removal of calculi under direct vision, short course of treatment, simple operation, and high clinical efficacy in the short term. It is suitable for patients with simple gallbladder calculi or solitary calculi, with normal gallbladder concentration and emptying function. In addition, it is also a good treatment method for elderly and weak patients with simple gallbladder calculi.

　　4. Surgical treatment

　　(1) Surgical treatment of gallbladder calculi: Cholecystectomy is the first-line method for gallbladder calculi. The operation can be classified into emergency surgery, early surgery, and elective surgery according to the condition. Emergency surgery is generally required in cases with acute suppurative cholecystitis, gangrenous cholecystitis, or gallbladder perforation, otherwise the patient may die due to suppurative peritonitis or sepsis. When calculi are impacted or non-surgical treatment is ineffective, surgery should be performed within 3 to 5 days of onset or treatment. For patients with mild symptoms and no significant complications, elective surgery should be considered under the following conditions: ① Patients with symptomatic calculi, diameter greater than 10mm or multiple calculi. ② Patients with gallbladder calculi complicated with secondary common bile duct calculi, acute cholecystitis, obstructive jaundice, or pancreatitis. ③ Patients with gallbladder calculi and suspected gallbladder cancer. ④ Patients with diabetes, whose blood sugar has been controlled to normal levels. ⑤ Elderly patients and/or those with cardiovascular and pulmonary dysfunction. In the latter two cases, the risk of emergency surgery is greater than that of elective surgery if an acute attack or complication occurs. Laparoscopic cholecystectomy (Laparoscopic cholecystectomy) recently developed is a minimally invasive operation that uses a laparoscope equipped with optical fibers and special surgical instruments inserted through 3 to 4 small incisions in the abdominal wall under the surveillance of a television screen to perform cholecystectomy. It has the characteristics of small trauma, less pain, and rapid postoperative recovery. Its contraindications include: ① Severe complications such as acute cholecystitis, acute pancreatitis, gallbladder empyema, perforation, gangrene, and Mirrizi syndrome. ② Functional asymptomatic gallbladder calculi. ③ Abdominal infection and sepsis. ④ Gallbladder cancer or suspected gallbladder cancer. ⑤ Severe bleeding disorders. ⑥ Severe cardiovascular and pulmonary dysfunction. ⑦ Pregnant women. ⑧ Jaundice, liver cirrhosis, and portal hypertension.

　　(2) Surgical Treatment of Extrahepatic Bile Duct Stones: Surgical treatment is the main method for extrahepatic bile duct surgery. It is generally believed that for patients with biliary tract obstruction for the first time, if systemic infection symptoms are severe, with persistent high fever, abdominal muscle tension, and marked tenderness, early surgery should be actively pursued. If symptoms are mild and symptoms are relieved after conservative treatment, and jaundice also subsides, surgery can be chosen. Common surgical methods are as follows:

　　① Cholecystolithotomy with T-tube Drainage: Suitable for simple bile duct stones, with patent upper and lower ends of the bile duct without stenosis and other diseases.

　　② Bileoenteric Anastomosis: Also known as bile-enteric internal drainage surgery, suitable for bile duct dilation ≥2.5cm, with inflammatory stricture obstructive disease at the lower end, but the upper bile duct must be patent without stenosis or cholelithiasis in sand and silt form, not easy to remove completely, with residual stones or a tendency for stones to recur.

　　③ Oddi Sphincteroplasty: Indications are the same as bile-enteric anastomosis surgery, especially for those with mild bile duct dilation that is not suitable for bile-enteric anastomosis surgery.

　　④ Endoscopic Sphincterotomy for Stone Removal: Suitable for bile stones impacted in the ampulla of Vater and the lower end of the common bile duct with benign stricture, especially for patients who have undergone cholecystectomy.

　　(3) Surgical Treatment of Intrahepatic Bile Duct Stones: The surgical principle for intrahepatic bile duct stones is to remove the stones as completely as possible, correct bile duct stenosis, and establish a bile-enteric channel with smooth drainage. Common surgical methods include the following:

　　① Cholecystolithotomy: After the stones are completely removed, a T-tube is placed for drainage.

　　② Internal Drainage Surgery: Internal drainage surgery includes Roux-en-Y anastomosis between intrapulmonary bile duct and jejunum, and interposed jejunal bile duct duodenal anastomosis.

　　③ Partial Hepatectomy or Lobectomy: For multiple bile duct stones in the liver that are localized to one lobe and cannot be removed or accompanied by lobar atrophy, partial (segmental) hepatectomy or lobectomy can be performed.

　　5. Symptomatic Treatment

　　(1) Enhancement of Bile Excretion: 50% magnesium sulfate solution 10-15ml can be taken orally after meals, 3 times a day, to relax the Oddi sphincter, promote bile excretion, enhance bile secretion therapy, used during the symptom relief period and lasting for several weeks, can reduce the recurrence of symptoms.

　　(2) Elimination of Biliary Colic: Mild colic can be treated with rest in bed, enema, and anal exhaust. For severe cases, fasting, gastrointestinal decompression, and intravenous fluid infusion should be given, and sedatives, antispasmodics, such as promethazine (Phenergan), atropine, and nitroglycerin can be administered. If necessary, pethidine (Dolantin) can be injected intramuscularly, but due to the spasmogenic effect of morphine on the Oddi sphincter, it should be used with caution.

　　6. Other Treatments

　　Ear pressure litholysis therapy has certain efficacy for patients with a small number of gallstones in the gallbladder and normal gallbladder function, and is currently widely used in China. Acupuncture therapy: The main acupoints are the日月, Qimen, Ganyu, gallbladder point, and Yanglingquan. Acupuncture treatment after 30 minutes of a fatty meal can improve the efficacy of stone expulsion, and is effective for biliary sandy stones. When biliary colic attacks occur, pressing the Ganyu and Ganyu points on the back can also play a certain role. In addition, some traditional Chinese medicines also have the effects of promoting bile flow, expelling stones, and clearing heat, and are widely used in clinical practice.

　　7. Optimal Treatment Plan

　　(1) Oral Litholysis Treatment Plan: For asymptomatic primary gallstones less than 15mm in size, without symptoms and signs of cholecystitis, oral medication for litholysis can be administered. Cholic Acid (CDCA): 370-750mg/d, Ursodeoxycholic Acid (UDCA): 150-450mg/d.

　　(2) Lithotripsy Plan: For patients with normal gallbladder function, less than 20mm in diameter, and no more than 2 to 3 stones, extracorporeal shock wave lithotripsy can be chosen for treatment.

　　(3) Surgical Treatment Plan: For patients with no effect from oral litholysis, a history of recurrent cholecystitis, and a tendency to develop gallbladder neck or common bile duct stones, surgical treatment should be scheduled.

　　8. Rehabilitation Treatment

　　For asymptomatic elderly patients with gallstones, active health education should be carried out, a reasonable diet structure should be maintained, and appropriate physical exercise should be enhanced to keep healthy and happy.

　　For elderly patients with symptoms, in addition to appropriate treatment, psychological treatment should be provided to alleviate the fear of the disease, and appropriate acupuncture and massage should be carried out to alleviate symptoms, actively cooperate with doctors' treatment, and promote the early recovery of the disease.

　　In summary, as a common disease in the elderly, cholelithiasis should receive increasing attention from clinical doctors.

　　II. Prognosis

　　The treatment of cholelithiasis is effective, and death is often due to complications such as gallbladder perforation, cholangitis, liver abscess, or acute pancreatitis.