Cholelithiasis is a disease accompanied by the formation of gallstones in the gallbladder (cholecystolithiasis) or in the bile ducts (choledocholithiasis). Stones are formed as a result of precipitation of bile pigments, cholesterol, certain types of proteins, calcium salts, infection of bile, its stagnation, lipid metabolism disorders. The disease may be accompanied by pain in the right hypochondrium, biliary colic, jaundice. Surgical intervention is required. Pathology can be complicated by cholecystitis, the formation of fistulas, peritonitis.
Cholelithiasis is a disease characterized by a disorder of the synthesis and circulation of bile in the hepatobiliary system as a result of a violation of cholesterol or bilirubin metabolism, as a result of which stones (concretions) are formed in the bile ducts and gallbladder. Pathology is dangerous with the development of severe complications with a high probability of death. The disease develops much more often in women. The treatment is carried out by specialists in the field of clinical gastroenterology and abdominal surgery.
Causes of cholelithiasis
In case of violation of the quantitative ratio of bile components in the body, the formation of solid formations (flakes) occurs, which over the course of the disease grow and merge into stones. The most common is cholelithiasis with impaired cholesterol metabolism (its excessive content in bile). Cholesterol-saturated bile is called lithogenic. Excess cholesterol is formed due to the following factors:
- Obesity and the use of a large number of cholesterol-containing products.
- With a decrease in the amount of bile acids entering the bile (decreased secretion during estrogenism, deposition in the gallbladder, functional insufficiency of hepatocytes).
- With a decrease in the amount of phospholipids, which, like bile acids, do not allow cholesterol and bilirubin to solidify and settle.
- With stagnant phenomena in the bile circulation system (thickening of bile due to absorption of water and bile acids in the gallbladder).
Stagnation of bile, in turn, can have a mechanical and functional character. With mechanical stagnation, there is an obstacle to the outflow of bile from the bladder (tumors, adhesions, kinks, enlargement of nearby organs and lymph nodes, scars, inflammation with edema of the wall, strictures). Functional disorders are associated with a disorder of the motility of the gallbladder and biliary tract (biliary dyskinesia by hypokinetic type). Also, infections, inflammation of the organs of the biliary system, allergic reactions, autoimmune conditions can lead to the development of cholelithiasis.
Risk factors for the development of cholelithiasis are elderly and senile age, taking medications that interfere with the metabolism of cholesterol and bilirubin (fibrates, estrogens during menopause, ceftriaxone, ocreotide), genetic factors (cholelithiasis in the mother), eating disorders (obesity, sudden weight loss, starvation, elevated cholesterol and high-density blood lipoproteins, hypertriglyceremia).
The likelihood of developing pathology is increased by multiple pregnancies, metabolic diseases (diabetes mellitus, fermentopathy, metabolic syndrome), diseases of the gastrointestinal tract (Crohn’s disease, duodenal diverticula and bile duct, biliary tract infection), postoperative conditions (after gastric resection, stem vagoectomy).
Gallstones are diverse in size, shape, there may be a different number of them (from one concretion to hundreds), but they are all divided according to their predominant component into cholesterol and pigment (bilirubin).
Cholesterol stones are yellow, consist of undissolved cholesterol with various impurities (minerals, bilirubin). Almost the vast majority of stones are of cholesterol origin (80%). Pigment stones of dark brown up to black color are formed with an excess of bilirubin in the bile, which happens with functional disorders of the liver, frequent hemolysis, infectious diseases of the bile ducts.
According to the modern classification , cholelithiasis is divided into three stages:
- Initial (pre-stone). Characterized by changes in the composition of bile) is not clinically manifested, it can be detected by biochemical analysis of the composition of bile.
- Formation of stones. Latent calcification is also asymptomatic, but with instrumental diagnostic methods, it is possible to detect concretions in the gallbladder.
- Clinical manifestations. It is characterized by the development of acute or chronic calculous cholecystitis.
Sometimes there is a fourth stage – the development of complications.
The symptomatology manifests itself depending on the localization of stones and their size, the severity of inflammatory processes and the presence of functional disorders. A characteristic pain symptom in GI is biliary or hepatic colic – pronounced acute sudden pain under the right rib of a cutting, stabbing nature. After a couple of hours, the pain finally concentrates in the area of the projection of the gallbladder. It can radiate into the back, under the right shoulder blade, into the neck, into the right shoulder. Sometimes irradiation to the heart area can cause angina pectoris.
Pain occurs more often after eating spicy, spicy, fried, fatty foods, alcohol, stress, heavy physical exertion, prolonged work in an inclined position. The causes of pain syndrome are spasm of the muscles of the gallbladder and ducts as a reflex response to irritation of the wall with concretions and as a result of overstretching of the bladder with excess bile in the presence of obturation in the biliary tract. Global cholestasis with blockage of the bile duct: the bile ducts of the liver expand, increasing the organ in volume, which responds with a painful reaction of an overgrown capsule. Such pain has a constant dull character, often accompanied by a feeling of heaviness in the right hypochondrium.
Concomitant symptoms are nausea (up to vomiting, which does not bring relief). Vomiting occurs as a reflex response to irritation of the periarticular area of the duodenum. If the inflammatory process has captured the pancreatic tissue, vomiting can be frequent, with bile, indomitable. Depending on the severity of intoxication, there is an increase in temperature from subfebrile digits to severe fever. With blockage of the concretion of the common bile duct and obstruction of the sphincter of Oddi, obstructive jaundice and fecal discoloration are observed.
The most common complication of GI is inflammation of the gallbladder (acute and chronic) and obstruction of the biliary tract by concretion. Blockage of the lumen of the biliary tract in the pancreas can cause acute biliary pancreatitis. Also, a frequent complication of cholelithiasis is considered to be inflammation of the bile ducts – cholangitis.
If the symptoms of hepatic colic are detected, the patient is referred for consultation by a gastroenterologist. Physical examination of the patient reveals symptoms characteristic of the presence of concretions in the gallbladder: Zakhariin, Ortner, Murphy. It also determines the soreness of the skin and the tension of the abdominal wall muscles in the area of the projection of the gallbladder. Xanthemums are noted on the skin, with obstructive jaundice, the characteristic yellow-brownish color of the skin and sclera.
A general blood test during a clinical exacerbation shows signs of nonspecific inflammation – leukocytosis and a moderate increase in ESR. A blood test reveals hypercholesterolemia and hyperbilirubinemia, an increase in the activity of alkaline phosphatase. With cholecystography, the gallbladder is enlarged, has calcareous inclusions in the walls, the stones with lime present inside are clearly visible.
The most informative and most widely used method of examining the gallbladder is ultrasound of the abdominal cavity. It accurately shows the presence of echo–tight formations – stones, pathological deformations of the walls of the bladder, changes in its motor skills. On ultrasound, the presence of signs of cholecystitis is clearly visible. Also, MRI and CT of the biliary tract allows you to visualize the gallbladder and ducts. Scintigraphy of the biliary system and ERCP (endoscopic retrograde cholangiopancreatography) are informative in terms of detecting violations of bile circulation.
Detection of the presence of gallstones without complications, as a rule, does not require specific treatment – resort to the so-called wait-and-see tactics. If acute or chronic calculous cholecystitis develops, removal of the gallbladder as a source of stone formation is indicated. Surgical intervention (cholecystotomy) is abdominal or laparoscopic, depending on the state of the body, pathological changes in the walls of the bladder and surrounding tissues, the size of concretions. Cholecystectomy from a mini-access can always be transferred to an open cavity operation in case of technical necessity.
There are methods of dissolving concretions with the help of ursodeoxycholic and henodeoxycholic acid preparations, but this kind of therapy does not lead to a cure for gallstone disease and over time the formation of new stones is possible. Another way to destroy stones is shock wave lithotripsy – it is used only in the presence of a single concretion and in patients who do not suffer from acute inflammation of the gallbladder or ducts.
Prognosis and prevention
The forecast directly depends on the rate of formation of stones, their size and mobility. In the overwhelming majority of cases, the presence of gallstones leads to the development of complications. With successful surgical removal of the gallbladder, there is a cure without pronounced consequences for the quality of life of patients. Prevention consists in avoiding factors contributing to increased cholesterol and bilirubinemia, stagnation of bile.
A balanced diet, normalization of body weight, an active lifestyle with regular physical activity help to avoid metabolic disorders, and timely detection and treatment of pathologies of the biliary system (dyskinesia, obturation, inflammatory diseases) reduces the likelihood of bile stasis and precipitation in the gallbladder. Particular attention should be paid to cholesterol metabolism and the state of the biliary system to persons with a genetic predisposition to stone formation.
In the presence of gallstones, the prevention of biliary colic attacks will be adherence to a strict diet (exclusion of fatty, fried foods, muffins, confectionery creams, sweets, alcohol, carbonated drinks, etc.), normalization of body weight, the use of a sufficient amount of liquid. To reduce the likelihood of movement of concretions from the gallbladder through the ducts, work associated with prolonged being in an inclined position is not recommended.