How is gallstone disease treated? GSD: symptoms

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What is gallstone disease?

Cholelithiasis is a pathology characterized by the formation of stones ( stones) V gallbladder. This disease is also called cholelithiasis or calculous cholecystitis. It is very common throughout the globe, found in all countries and among representatives of all races. Cholelithiasis refers to pathologies of the digestive tract, and its treatment is usually carried out by gastroenterologists.

In medicine, it is customary to distinguish between several variants of cholelithiasis. Firstly, stone-carrying occurs, which is not always classified as a pathological condition. A number of experts even suggest considering it separately from the calculous cholecystitis. Stone-carrying is the process of formation of stones in the gall bladder, which is not accompanied by any symptoms or disorders. It occurs in almost 15% of the population, but is not always detected. Often, stones are unexpectedly discovered during a preventative ultrasound or x-ray examination.

The second variant of the disease is gallstone disease itself with all its symptoms and manifestations. Gallstones can cause the most various disorders, most of which are related to the digestion process. Finally, the third variant of this pathology is biliary colic. These are sharp pains that usually appear in the right hypochondrium. In fact, colic is only a symptom of the disease. However, most patients are unaware of their illness or do not seek medical attention until this symptom appears. Because biliary colic is an acute condition that requires urgent medical attention, it is sometimes considered a separate syndrome.

The prevalence of gallstone disease is not the same in at different ages. In children and adolescents, this pathology is rarely detected, since the formation of stones takes quite a long time. As you age, the risk of stone formation increases, as does the risk of severe complications.

The prevalence of calculous cholecystitis by age is as follows:

• 20 – 30 years– less than 3% of the population;
• 30 – 40 years– 3 – 5% of the population;
• 40 – 50 years– 5 – 7% of the population;
• 50 – 60 years– up to 10% of the population;
• Over 60 years old– up to 20% of the population, and the risk increases with age.

It has also been noted that women suffer from cholelithiasis much more often than men, approximately in a ratio of 3 to 1. Among the female population North America Currently, the highest incidence of cholelithiasis is observed. According to various sources, it ranges from 40 to 50%.

There are several theories about the causes of this disease. Most experts are inclined to believe that calculous cholecystitis is the result of the influence of a whole complex of various factors. On the one hand, this is confirmed by statistical data, on the other hand, it does not explain the appearance of stones in those people who are not influenced by these factors.

In many cases, cholelithiasis is indicated surgery– removal of the gallbladder along with stones. This pathology occupies an important place in surgical hospitals. Despite the risk of serious complications that exists with cholelithiasis, mortality from it in developed countries is not high. The prognosis of the disease usually depends on timely diagnosis and proper treatment.

Causes of gallstone disease

Gallstone disease itself has one specific reason– stones ( stones), which are located in the gallbladder. However, the mechanism and reasons for the formation of these stones may be different. To better understand them, you should understand the anatomy and physiology of the gallbladder.

The gallbladder itself is a small hollow organ with a volume of 30–50 ml. In the abdominal cavity it is located in the upper right part, adjacent to the lower ( visceral) surface of the liver. It borders the duodenum, the liver itself, the bile duct, and the head of the pancreas.

The structure of the gallbladder consists of the following parts:

• Bottom– the upper part adjacent to the liver from below.
• Body– the central part, limited by the side walls of the bubble.
• Neck- the lower, funnel-shaped part of the organ, which passes into the bile duct.

The bile duct itself is a narrow tube through which bile flows from the bladder into the duodenum. In the middle part, the bile duct unites with the common hepatic duct. Just before it enters the duodenum, it merges with the excretory duct of the pancreas.

The main function of the gallbladder is the storage of bile. Bile itself is formed by liver cells ( hepatocytes) and flows from there along the common hepatic duct. Since bile is necessary specifically for the digestion of fats after meals, there is no need for its constant supply to the intestines. That is why it accumulates “in reserve” in the gallbladder. After eating, the smooth muscles in the walls of the gallbladder contract, and large amounts of bile are quickly released ( which the liver itself is not capable of, since bile is formed in it gradually at the same speed). Thanks to this, fats are emulsified, they are broken down and absorbed.

Bile is a fluid produced by hepatocytes, the cells of the liver. Its most important components are cholic and chenodeoxycholic acids, which have the ability to emulsify fats. These acids contain a compound called cholesterol ( fat soluble cholesterol). Bile also contains compounds called phospholipids, which keep cholesterol from crystallizing. When the concentration of phospholipids is insufficient, so-called lithogenic bile begins to accumulate. In it, cholesterol gradually crystallizes and combines into stones - gallstones themselves.

Bile also contains the pigment bilirubin. It is formed from hemoglobin after the breakdown of red blood cells ( red blood cells are destroyed from “old age” in 120 days). Bilirubin enters the blood and is transported to the liver. Here it is conjugated ( contacts) with other substances ( into the bound fraction of bilirubin) and is excreted in bile. Bilirubin itself is toxic and can irritate some tissues in high concentrations ( itching in the skin, irritation of the membranes of the brain, etc.). When there is an excessive concentration of bilirubin in the blood and bile, it can form compounds with calcium ( calcium bilirubinate), which form the stones. Such stones are also called pigment stones.

No common causes and mechanisms for the formation of gallstones have been identified at the moment. However, there is extensive list various factors and associated disorders that greatly increase the risk of stone formation. Since none of them leads to cholelithiasis in 100% of cases, they are usually called predisposing factors. In practice, a patient with cholelithiasis almost always has a combination of several of these factors.

It is believed that the risk of gallstones is directly related to exposure to the following factors:

• Cirrhosis of the liver. With alcoholic cirrhosis of the liver, changes occur in the composition of the blood. As a result, increased production of bilirubin is possible, and there is a higher likelihood of pigment stones forming.
• Crohn's disease. Crohn's disease is an inflammatory lesion of the digestive tract with a presumably autoimmune mechanism of development. The inflammatory process can develop in various parts of the gastrointestinal tract, but the intestines are most often affected. The disease is chronic and occurs with for long periods remission ( subsidence of symptoms). It has been statistically noted that patients with Crohn's disease are more likely to develop gallstones.
• Lack of plant fiber in food. Plant fibers are found mainly in vegetables and a number of grains. The lack of these products in the diet disrupts the functioning of the intestines, and the excretion of feces worsens. Intestinal dysfunction also affects the contractility of the gallbladder. There is a high risk of bile stagnation, which predisposes to the formation of stones.
• Resection ( deletion) ileum. Removal of part of the ileum is sometimes done if there are suspicious formations in it ( tumors), rarely – polyps, diverticula or after abdominal injuries. Since a significant part is absorbed here nutrients, its removal affects the work digestive system generally. The risk of developing gallstones in such patients is thought to be increased.
• Taking hormonal contraceptives ( COOK). It is noted that excess estrogen ( female sex hormones) is generally a predisposing factor to cholelithiasis. The effect of combined oral contraceptives ( COOK) is usually based precisely on an increase in the amount of estrogen. This may partly explain the higher prevalence of gallstone disease among women. In addition to COCs, excess estrogen can be observed in hormone-producing tumors and a number of gynecological diseases.
• Some hematological diseases. The pigment bilirubin, which often forms stones, is formed from hemoglobin. Hemoglobin enters the blood after the breakdown of red blood cells. Normally, the body destroys a certain number of old cells. However, in a number of pathologies, hemolysis can occur - the simultaneous destruction of red blood cells in large quantities. Hemolysis can be triggered by infections, toxins, disorders at the bone marrow level and a number of other reasons. As a result, red blood cells break down faster, releasing more hemoglobin and producing excess bilirubin. Accordingly, the risk of gallstone formation increases.
• Infectious process. Can play a certain role infectious processes at the level of the bile ducts. Most often, opportunistic microorganisms from the intestines act as infectious agents ( Escherichia coli, enterococci, clostridia, etc.). Some of these microbes produce a special enzyme, beta-glucuronidase. Getting into the bile in the cavity of the bladder, these enzymes contribute to the binding of bilirubin into stones.
• Sclerosing cholangitis. Sclerosing cholangitis is a pathology in which, against the background chronic inflammation The lumen of the bile duct gradually narrows. Because of this, the outflow of bile is disrupted, it stagnates in the bladder, and favorable conditions arise for the formation of stones. Thus, with this pathology, a violation of the outflow of bile precedes the formation of stones. First, the patient will develop jaundice and digestive disorders, and only then - colic due to the growth of stones and spastic contraction of the bladder walls.
• Some pharmacological drugs. Taking a number of medications ( especially long lasting) can affect the functioning of the liver and, through it, the composition of bile. As a result, bilirubin or cholesterol will precipitate and form stones. This feature has been observed in some drugs containing estrogens ( female sex hormones), somatostatin, fibrates.

In addition, the likelihood of gallstones forming and the rate at which they grow can be influenced by a number of factors beyond a person's control. For example, more high risk women are susceptible compared to men and older people compared to young people. Heredity also plays a role. It is believed that the average growth rate of stones is 1–3 mm per year, but during pregnancy it can increase sharply, causing an exacerbation of cholelithiasis. Thus, a large number of pregnancies in a woman ( including abortions) predisposes to the formation of gallstones.

Classification of cholelithiasis

There are several options for classifying cholelithiasis, which are based on various criteria. The main classification can be called the division of stone carriers and gallstone disease itself. Both of these terms imply the presence of gallstones. However, in the first case, with stone carriers, the patient does not have any manifestations, symptoms or signs of the disease at all. Gallstone disease refers to the same condition, but at a stage when there are different clinical manifestations. At first they may be very minor, but gradually progress.

Among other classifications of cholelithiasis, it should be noted that it is divided according to the type of stones, their number, size and location, as well as the course of the disease. In each case, the disease will have its own characteristics, and therefore may require a different approach to treatment.

Based on the chemical composition of stones, the following types of gallstone disease are distinguished:

• Cholesterol. Cholesterol is a normal component of bile, but excess can lead to the formation of stones. This substance enters the body with food and must be properly absorbed in order to promote various physiological processes. Impaired absorption leads to its increased concentration in bile. Cholesterol stones are usually round or oval, reach 1–1.5 cm in diameter and are often located at the bottom of the gallbladder.
• Bilirubin ( pigment). The basis of these stones is the pigment bilirubin, which is formed after the breakdown of hemoglobin. Stones usually form when its content in the blood is high. Pigment stones are smaller than cholesterol stones. Usually there are more of them, and they can be found not only in the gallbladder, but also enter the bile ducts.

Also, gallstones have varying degrees of calcium saturation. This largely determines how well they are visible on ultrasound or radiography. In addition, the degree of calcium saturation influences the choice of treatment method. Calcified stones are more difficult to dissolve with medication.

In general, the classification of the disease according to the chemical composition of stones is rather of scientific interest. In practice, the manifestations of the disease will be similar, and it is almost impossible to distinguish these types by symptoms. However, the composition of the stones indicates concomitant disorders in the body, which also need to be corrected. In addition, as noted above, the method of medicinal dissolution of stones is not suitable in all cases.

According to the number of stones, individual stones are distinguished accordingly ( less than 3) and multiple ( 3 or more) stones. In principle, the fewer stones, the simpler the treatment should be. However, here great importance They also have their sizes. The manifestations of the disease with single or multiple stones are the same. Differences appear only with ultrasound examination, which visualizes stones.

It is customary to distinguish the following types of stones by size:

• Small ones. The size of these stones does not exceed 3 cm. If the stones are single and located in the bottom of the bladder, the patient usually does not have acute symptoms.
• Large ones. Large stones with a diameter of more than 3 cm often disrupt the flow of bile and cause biliary colic and other severe manifestations of the disease.

The size of the stones may influence the choice of treatment tactics. Large stones are usually not dissolved, and their crushing with ultrasonic waves is unlikely to give good effect. In these cases, surgical removal of the bladder along with its contents is recommended. For small stones, alternative, non-surgical treatment methods can be considered.

Sometimes attention is also paid to the location of gallstones. Stones located at the bottom of the gallbladder are less likely to cause any symptoms. Stones located in the cervical area can clog the bile duct and cause bile stagnation. Accordingly, they are more likely to cause any symptoms associated with pain or digestive disorders.

There are also the following forms of cholelithiasis itself:

• Latent form. In this case, we are talking about stone-bearing, which does not manifest itself in any way and is discovered, as a rule, by accident.
• Symptomatic uncomplicated form. This form is characterized by various symptoms from the digestive system or pain in the form of typical biliary colic. In other words, typical manifestations for this pathology are present.
• Symptomatic complicated form. In this case, the patient experiences not only symptoms characteristic of cholelithiasis, but also signs of damage to other organs. This may include atypical pain, liver enlargement, etc.
• Atypical form. As a rule, this form of the disease includes unusual manifestations of cholelithiasis. For example, pain syndrome can sometimes occur not in the form of biliary colic, but imitate the pain of appendicitis ( in the right lower abdomen) or angina ( chest pain). In these cases, making a correct diagnosis is difficult.

During the diagnostic process, it is very important to find out exactly what form of the disease the patient is suffering from. A detailed classification according to all of the above criteria will allow us to more clearly formulate the diagnosis and prescribe more correct treatment.

Stages of gallstone disease

Like any disease, gallstone disease goes through several stages in its development. Each of these stages is directly related to such characteristics of the disease as the clinical course, the size of the stones, the presence of complications, etc. Thus, the conditional division of the disease into stages is based on the various classifications listed above.

During gallstone disease the following stages can be distinguished:

• Physico-chemical stage. At this stage, there are no stones in the gall bladder yet, but the patient has the prerequisites for their appearance. There is a disruption in the formation of normal bile. The liver begins to produce lithogenic bile rich in cholesterol, or the patient experiences increased secretion bilirubin. In both cases, direct preconditions for the formation of stones are created. Sometimes this stage is also called pre-disease. It is very difficult to detect disturbances in the formation of bile. Actually, there are no stones in the gall bladder yet, but special tests are needed to identify physicochemical changes. A bile sample can be obtained by probing, but it is not prescribed to patients without any pathologies as a preventive or diagnostic method. Sometimes the procedure is prescribed to those patients who have diseases that predispose them to the formation of stones ( hemolytic anemia, increased level cholesterol, liver disease, etc.). However, in general, the disease is not diagnosed at the pre-disease stage.
• Stone-carrying. At the stone-carrying stage, stones of various sizes may be found in the gallbladder ( even large ones), but there are no symptoms of the disease. Stones can be detected by ultrasound or x-ray, but these diagnostic methods also usually not prescribed during a preventive examination. Thus, cholelithiasis at this stage is usually diagnosed by chance.
• Clinical stage. The onset of the clinical stage almost always coincides with the first attack ( first ever biliary colic). Patients may already suffer from vague pain in the right hypochondrium or periodic bowel movements. However, they do not always consult a doctor about this. With colic, the pain is very severe, so it usually becomes the reason for a full examination. The clinical stage is characterized by periodic colic, intolerance fatty foods and other typical symptoms. Diagnosing the disease during this period is usually not difficult.
• Complications. The stage of complications with cholelithiasis can occur quite quickly. In some patients, literally on the second or third day after the first colic, the temperature rises, constant dull pain in the abdomen and other symptoms occur, which are rare in an uncomplicated course of the disease. In fact, the onset of this stage depends on the movement of stones and the entry of pathogens into the gallbladder. In many patients it never occurs. The stage of clinical complications can last for years and end with a successful recovery ( removal or dissolution of stones).

Dividing the disease into stages in most cases does not have serious clinical significance. It relies on the processes that occur in the body, but does not greatly influence the choice of diagnostic or treatment method. In principle, the more advanced the disease, the more difficult it is to treat. But sometimes uncomplicated cholecystitis can create many problems with treatment.

Symptoms and signs of gallstone disease

In principle, cholelithiasis can be very for a long time proceed without any symptoms or manifestations. This is explained by the fact that the stones in the early stages are small, do not clog the bile duct and do not injure the walls. The patient may not even suspect that he has this problem for a long time. In these cases, they usually talk about stone-carrying. When gallstone disease itself makes itself felt, it can manifest itself in different ways.

Among the first symptoms of the disease, one should note heaviness in the abdomen after eating, stool disturbances ( especially after eating fatty foods), nausea and mild jaundice. These symptoms may appear even before severe pain in the right hypochondrium - the main symptom of cholelithiasis. They are explained by unexpressed disturbances in the outflow of bile, which makes the digestion process worse.

Most characteristic of cholelithiasis following symptoms and signs:

• Pain in the right hypochondrium. The most typical manifestation of cholelithiasis is the so-called gallstone ( biliary, hepatic) colic. This is an attack of acute pain, which in most cases is localized at the intersection of the right costal arch and the right edge of the rectus abdominis muscle. The duration of an attack can vary from 10–15 minutes to several hours. At this time, the pain can be very severe, radiating to the right shoulder, back or other areas of the abdomen. If an attack lasts more than 5–6 hours, then you should think about possible complications. The frequency of attacks may vary. Often, about a year passes between the first and second attack. However, in general, they become more frequent over time.
• Temperature increase. An increase in temperature usually indicates acute cholecystitis, which often accompanies cholelithiasis. An intense inflammatory process in the area of ​​the right hypochondrium leads to the release of active substances into the blood that contribute to a rise in temperature. Prolonged pain after colic accompanied by fever almost always indicates acute cholecystitis or other complications of the disease. Periodic increase temperature ( wavy) with a rise above 38 degrees may indicate cholangitis. However, in general, fever is not a mandatory symptom of gallstone disease. The temperature may remain normal even after severe, prolonged colic.
• Jaundice. Jaundice occurs due to stagnation of bile. The pigment bilirubin is responsible for its appearance, which is normally secreted with bile into the intestines, and from there is excreted from the body with feces. Bilirubin is a natural metabolic product. If it ceases to be excreted in the bile, it accumulates in the blood. This is how it spreads throughout the body and accumulates in tissues, giving them a characteristic yellowish tint. Most often, the sclera of the eyes turn yellow in patients first, and only then the skin. In fair-skinned people, this symptom is more noticeable, but in dark-skinned people, unexpressed jaundice may even be missed experienced doctor. Often, simultaneously with the appearance of jaundice in patients, the urine also darkens ( dark yellow, but not brown). This is explained by the fact that the pigment begins to be released from the body through the kidneys. Jaundice is not a mandatory symptom of calculous cholecystitis. Also, it does not appear only with this disease. Bilirubin can also accumulate in the blood due to hepatitis, liver cirrhosis, some hematological diseases or poisoning.
• Fat intolerance. IN human body bile is responsible for emulsification ( dissolution) fats in the intestines, which is necessary for their normal breakdown, absorption and assimilation. With cholelithiasis, stones in the cervix or bile duct often block the path of bile to the intestines. As a result, fatty foods are not broken down normally and cause intestinal disturbances. These disorders may manifest as diarrhea ( diarrhea), accumulation of gases in the intestines ( flatulence), mild abdominal pain. All these symptoms are nonspecific and can occur with various gastrointestinal diseases ( gastrointestinal tract ). Intolerance to fatty foods can also occur at the stone-carrying stage, when other symptoms of the disease are still absent. At the same time, even a large stone located at the bottom of the gallbladder may not block the flow of bile, and fatty foods will be digested normally.

In general, the symptoms of cholelithiasis can be quite varied. There are various stool disorders, atypical pain, nausea, and periodic bouts of vomiting. Most doctors are aware of this variety of symptoms, and just in case, they prescribe an ultrasound of the gallbladder to exclude cholelithiasis.

How does an attack of cholelithiasis manifest?

An attack of cholelithiasis usually means biliary colic, which is the most acute and typical manifestation of the disease. Stone carriage does not cause any symptoms or disorders, and patients usually do not attach importance to mild digestive disorders. Thus, the disease proceeds latently ( is hidden).

Biliary colic usually appears suddenly. Its cause is a spasm of smooth muscles located in the walls of the gallbladder. Sometimes the mucous membrane is also damaged. Most often this happens if the stone moves and gets stuck in the neck of the bladder. Here it blocks the outflow of bile, and bile from the liver does not accumulate in the bladder, but flows directly into the intestines.

Thus, an attack of cholelithiasis usually manifests itself as characteristic pain in the right hypochondrium. At the same time, the patient may experience nausea and vomiting. Often an attack occurs after sudden movements or exertion, or after eating a large amount of fatty food. Once during an exacerbation, stool discoloration may be observed. This is explained by the fact that pigmented ( painted) bile from the gallbladder. Bile from the liver flows only in small quantities and does not give intense color. This symptom called acholia. In general, the most typical manifestation of an attack of cholelithiasis is characteristic pains, which will be described below.

Pain due to cholelithiasis

Pain due to cholelithiasis differs in various stages. With stones, there is no pain as such, but some patients complain of discomfort in the upper abdomen or in the right hypochondrium. Sometimes it can be caused by a buildup of gases. At the stage of clinical manifestations of the disease, more accentuated pain appears. Their epicenter is usually located in the area of ​​the right costal arch, 5–7 cm from the midline of the abdomen. However, atypical pain is sometimes possible.

The most common form of gallstone pain is biliary colic. It occurs suddenly, and patients often feel that the cause of the pain is muscle spasm. The pain gradually increases and usually reaches its peak after 30 to 60 minutes. Sometimes colic goes away faster ( in 15 – 20 minutes), and sometimes lasts several hours. The pain is very strong, the patient cannot find a place for himself and cannot take a comfortable position so that the pain goes away completely. In most cases, it is when biliary colic occurs that patients turn to a doctor for qualified help, even if they previously ignored all the symptoms of the disease.

Pain from biliary colic can radiate to the following areas:

• lower right abdomen ( can be confused with appendicitis);
• “in the pit of the stomach” and in the area of ​​the heart;
• to the right shoulder;
• into the right shoulder blade;
• in the back.

Most often it is the spread ( irradiation) pain, but sometimes there is almost no pain in the right hypochondrium. Then it is difficult to suspect biliary colic during examination.

Often pain occurs when pressing on the corresponding area or when tapping on the right costal arch. It should be remembered that pain in the right hypochondrium ( and even biliary colic) do not always indicate the presence of gallstones. They can be observed with cholecystitis ( inflammation of the gallbladder) without the formation of stones, as well as with dyskinesia biliary tract.

Gallstone disease in children

In general, cholelithiasis in children is extremely rare and is rather an exception to the rule. The fact is that it usually takes a long time for stones to form. Cholesterol crystals or bilirubin compact and form a stone slowly. In addition, hypercholesterolemia itself is rare in children. They are not subject to many of the predisposing factors that affect adults. First of all, these are fatty and heavy foods, physical inactivity ( sedentary lifestyle), smoking and alcohol. Even if these factors are present, the child’s body copes with them much better than an adult. Thus, the likelihood of developing gallstones in children is greatly reduced. The current prevalence of calculous cholecystitis ( among children with gastrointestinal diseases) is no more than 1%.

In most children, cholelithiasis manifests itself differently than in adults. Biliary colic occurs rarely. The clinical picture is observed more often ( symptoms and manifestations) gastritis, peptic ulcer, colitis and other gastrointestinal diseases. An acute inflammatory process rarely complicates the course of the disease. Fat intolerance, stool disorders, nausea and vomiting are common.

Confirmation of the diagnosis and treatment of pathology is not very different from those in adults. Cholecystectomy ( gallbladder removal) is required quite rarely. Sometimes necessary surgical correction abnormalities of the bile ducts.

Gallstone disease during pregnancy

Gallstone disease in women during pregnancy is a very common problem. All such cases can be divided into two large groups. The first category includes patients who already have gallstones ( stone-bearing stage). In them, the disease most often passes into an acute stage under the influence of various factors that arise specifically during pregnancy. The second group includes patients in whom the intensive process of stone formation begins precisely during pregnancy ( that is, at the time of conception there were no stones yet). There are also a number of prerequisites for this.

The development of cholelithiasis during pregnancy is influenced by the following factors:

• Mechanical compression of an organ. The growth of the fetus during pregnancy causes an increase in pressure in the abdominal cavity. Many organs move upward as they grow, and in the third trimester, when the fetus is at its maximum size, the pressure becomes maximum. Kinking the gallbladder and squeezing the biliary tract can trigger an attack of the disease. Most often this happens in cases where there are already stones in the gall bladder, but the woman does not know about it.
• Changes in hormonal levels. Pregnancy is associated with significant hormonal changes in a woman’s body. During this period, the concentration of a number of hormones in the blood increases, which contribute to the formation of stones. For example, the hormone estriol, among other beneficial effects, helps increase cholesterol levels in the blood. Progesterone, the concentration of which is also high, impairs motility ( reductions) walls of the gallbladder, which causes stagnation of bile. Under the influence of these hormones, as well as due to a sedentary lifestyle, an intensive process of stone formation begins. Of course, it does not occur in all patients, but only in those who are predisposed to it ( there are other predisposing factors).
• Changes in diet. During pregnancy, many women experience changes in taste preferences and, as a result, changes in diet. An excess of foods rich in fats can provoke an attack, and the disease will move from stone-bearing to the stage of clinical manifestations. The mechanism of such exacerbation is quite simple. The gallbladder gets used to secreting bile in certain quantities. Regular intake of fatty foods requires more intense formation and secretion of bile. The walls of the organ contract intensely, and this leads to the movement of the stones present there.
• Taking certain medications. During pregnancy, patients for various reasons may be prescribed a number of drugs that promote the formation of gallstones. This may trigger an attack of illness.

It should be noted that the age of the expectant mother also plays a significant role. In young girls, cholelithiasis is rare, and therefore the risk of its exacerbation during pregnancy is lower. In adult women ( about 40 years or more) stone-bearing is more common. Accordingly, the risk of exacerbation of the disease during pregnancy is much higher.

Manifestations of cholelithiasis during pregnancy are generally not very different from those in other patients. The most typical acute pain is in the right hypochondrium ( biliary colic). If there is difficulty in the outflow of bile, darkening of the urine may occur ( it is saturated with bilirubin, which is not excreted in bile). It is also noted that toxicosis of pregnant women and a number of other complications of pregnancy are more common.

Diagnosis of cholelithiasis usually does not cause difficulties. Already in the first trimester of pregnancy, a competent doctor will conduct an ultrasound of the abdominal organs, which will reveal stone carriage. After this, an attack can be recognized even by typical symptoms. If the stones were not detected earlier, the diagnosis becomes somewhat more complicated. An atypical distribution of pain during an attack is possible, since many abdominal organs are displaced.

The most difficult stage is the treatment of patients with cholelithiasis during pregnancy. Many drugs that can help are not prescribed due to the risk to the fetus. However, during colic, in any case, pain is relieved with antispasmodics. Pregnancy is also not absolute contraindication for surgery and removal of the gallbladder along with stones. In these cases, they try to give preference to endoscopic methods. In this case, there are no large seams left, which may subsequently come apart during childbirth. Patients with cholelithiasis are hospitalized for constant monitoring and more thorough examination. If possible, they try to contain exacerbations with the help of diet and other preventive measures in order to carry out surgery after childbirth ( eliminate the risk to the child). Non-surgical treatment of stones ( ultrasonic crushing or dissolution) is not used during pregnancy.

It should also be noted that various complications of cholelithiasis are more common in pregnant women. This is explained by weakened immunity during this period and frequent displacement of stones. Self-medication in these cases is unacceptable, since an acute inflammatory process provoked by stones can threaten the life of both the mother and the fetus.

Complications of gallstone disease

The formation of gallstones is a slow process and usually takes more than one year. However, patients are advised to undergo prophylactic gallbladder ultrasound whenever possible to detect them on early stage. This is explained by the fact that the disease is fraught with various complications that are easier to prevent than to treat.

In most cases, complications of cholelithiasis arise due to the occurrence and spread of the inflammatory process in the abdominal cavity. The immediate cause is injury to the walls of the gallbladder by the sharp edges of the stones ( does not happen with all types of stones), blockage of the bile ducts and stagnation of bile. The most common surgical complications and disturbances in the digestive system.

In the absence of timely treatment of cholelithiasis, the following complications are possible:

• Empyema of the gallbladder. Empyema is an accumulation of pus in the cavity of the gallbladder. This happens only if pyogenic microorganisms enter there. Most often these are representatives of the intestinal microflora - Escherichia, Klebsiella, Proteus. The stones clog the neck of the gallbladder, and a cavity is formed in which these microorganisms can freely develop. As a rule, the infection enters here through the bile ducts ( from the duodenum), but in rare cases it can also be carried with blood. With empyema, the gallbladder is enlarged and painful when pressed. An increase in temperature and a significant deterioration in general condition are possible. Empyema of the gallbladder is an indication for urgent removal of the organ.
• Wall perforation. Perforation is a perforation through the wall of an organ. As a rule, it occurs in the presence of large stones and high blood pressure inside the organ. Rupture of the gallbladder can be caused by physical activity, sudden movement, or pressure on the right hypochondrium ( for example, using a seat belt when braking). This complication is the most dangerous, since it causes the flow of bile into the free abdominal cavity. Bile is highly irritating and quickly causes inflammation of the sensitive peritoneum ( membrane covering the abdominal organs). Microbes can also enter the free abdominal cavity from the gallbladder cavity. The result is a serious condition - biliary peritonitis. The inflammation involves the right upper part of the abdominal cavity, but can spread to other areas. The main symptoms of perforation are the appearance of sharp severe pain, an increase in temperature, a rapid deterioration in general condition, increased heart rate and breathing. In this case, the patient can only be saved by large-scale surgery combined with intensive antibiotic therapy. However, even timely hospitalization of the patient does not provide a 100% guarantee of a successful recovery.
• Hepatitis. In this case we are not talking about viral hepatitis (which are the most common), but about the so-called reactive hepatitis. It is explained by the proximity of the inflammatory focus, stagnation of bile, and the spread of infection ( if there are microbes in the gallbladder). As a rule, such hepatitis responds well to treatment and goes away quickly after removal of the gallbladder. Its main symptoms are heaviness in the right hypochondrium and enlarged liver.
• Acute cholangitis. Acute cholangitis is inflammation of the bile ducts connecting the gallbladder and duodenum. As a rule, it is caused by the entry of a smaller stone into the duct itself and damage to the mucous membrane. Unlike cholecystitis, which can occur without acute symptoms, cholangitis is almost always accompanied by high fever, pain and jaundice.
• Acute pancreatitis. The excretory duct of the pancreas, before flowing into the duodenum, connects with the bile duct. If a small gallstone becomes lodged at the level of the common duct, bile may leak into the pancreas. This body produces digestive enzymes that can break down proteins. These enzymes are normally activated by bile in the duodenum and break down food. Their activation in the cavity of the gland itself is fraught with destruction of organ tissue and acute inflammatory process. Pancreatitis is manifested by severe girdle pain in the upper abdomen. As a rule, pain appears suddenly. This disease poses a serious threat to life and requires urgent surgical treatment.
• Fistula formation. A fistula is a pathological connection of one hollow organ to another. It is usually the result of a long-term inflammatory process with gradual destruction of the wall. Fistulas of the gallbladder can connect its cavity directly to the abdominal cavity ( clinically resembles perforation), intestines or stomach. In all these cases, serious digestive problems and periodic pain will occur.
• Cirrhosis of the liver. In this case we are talking about the so-called secondary biliary cirrhosis of the liver. Its cause is the accumulation of bile in the intrahepatic ducts, since it does not flow into the overfilled gallbladder. After some time, the liver cells stop functioning normally and die. In their place, connective tissue is formed, which does not perform the functions that hepatocytes performed ( liver cells). The main symptoms are bleeding disorders ( the liver produces substances necessary for this process), intoxication of the body with its own metabolic products, stagnation of venous blood in portal vein which passes through the liver. Progression of the disease leads to hepatic coma and death of the patient. Despite the fact that liver cells are recovering well, treatment cannot be delayed. Cirrhosis is an irreversible process and the only effective method treatment is transplantation ( transfer) organ.
• Neoplasms of the gallbladder. Malignant neoplasms can appear in the gallbladder due to prolonged ( for many years) inflammatory process. The bile itself plays a certain role in this, with which some toxic substances can be released from the body. Gallbladder tumors can compress the bile ducts, duodenum, and grow into neighboring organs, disrupting their functions. Like all malignant neoplasms, they pose a direct danger to the patient’s life.

Due to the possibility of all these serious complications and a direct threat to the patient's life, in most cases doctors recommend cholecystectomy ( gallbladder removal) as the main method of treatment. Crushing gallstones with ultrasound or dissolving them does not always eliminate the risk of complications by 100%. Before use, you should consult a specialist.

Bilirubin poisoning can already cause a lot of trouble. Complications of cholelithiasis are detected after surgical intervention. In order for readers to understand the scope of the pathology, we note that today surgeons more often remove the gallbladder than the appendix. Gallstone disease is a common disease. In the Russian Federation, only hernias are excised more often than the gallbladder.

Doctors cannot determine the exact causes of gallstone disease. Although the mechanisms of stone formation have been fully studied. The most unpleasant situation seems to be the development of cirrhosis and, as a consequence, obstruction of the bile ducts. A person turns yellow from an excess of bilirubin. The process is dangerous - a host of reactions arises from the outside nervous system, including the central one.

In many cases, gallstone disease cannot be treated. The bubble is simply cut out, and the treatment ends there. However, 40% of patients continue to experience difficulties for various reasons. For example, high tone of the sphincter of Oddi, which does not release bile into the duodenum. Consequently, similar consequences appear.

Through bile, the body removes selected substances that cannot be removed otherwise. We're talking about bilirubin. Only a small fraction of the substance leaves the body in the urine. The rest is bound in the gallbladder, enters the intestines and is finally broken down by bacterial enzymes. Bile acids are absorbed and re-enter the liver in a slightly modified form. The influence is exerted by enzymes of bacteria of the large intestine.

Complications of surgery

• Relapses (re-formation of stones) after cholecystectomy (removal of the gallbladder) and cholecystostomy (excision of the bottom of the gallbladder). Stones appear inside the liver, in the stump of the gallbladder, and clog the ducts.
• Postoperative chronic (inflammatory) diseases in the stump of the gallbladder, ducts, diverticula, scarring of the tract, the appearance of fistulas, proliferation of connective or cancerous tissue, cirrhosis.
• Inflammatory processes of the biliary tract and the space immediately adjacent to the operation site:

1. Pancreatitis.
2. Cholecystitis of the stump with complications (peritonitis, abscess).
3. Liver or kidney failure.
4. Sepsis.
5. Mechanical jaundice.

• Damage to organs due to surgery, poor-quality sutures, ingestion foreign bodies, loss of drainage, hernia and tumor.
• Damage to the portal vein and branches, hepatic artery, pancreas, duodenum.
• Simulation from the nervous system, phantom pain, psychosis.

Often postoperative symptoms are not related to the measures taken and are caused by disorders of the musculoskeletal system (neuralgia, osteochondrosis).

Complications of gallstone disease

The appearance of stones is not always noticed. Gallstone disease is divided into a number of stages, the first being latent. The causes of complications lie in the disruption of bile acid metabolism. There is poor digestibility of fatty foods and indigestion. A number of conditions have been described, identified by doctors into special families.

Acute inflammation of the gallbladder

Cholecystitis in 90% of cases develops against the background of the presence of stones. Elderly seriously ill patients have a high mortality rate. Acute inflammation is divided by type into:

• Gangrenous.
• Phlegmonous.
• Catarrhal.

The process is preceded by an increase internal pressure organ up to 300 mm. Hg Art. The disease is accompanied by a violation of the outflow of bile and the appearance of specific biochemical signs. The process is suppressed by ibuprofen and indomethacin. In two thirds of cases, this is accompanied by bacterial growth, mainly caused by anaerobic strains of microbes. The formed cycle does not allow the patient to get out of the situation on his own.

At the initial stage, colic is pulsating in nature (visceral), then it becomes constant (somatic), the number of leukocytes and erythrocytes (precipitated) in the blood increases. As a result of the symptoms, the temperature often rises, and in some cases a jaundiced skin color is noted. When palpated, the muscles of the right side of the hypochondrium are noticeably tense, the bladder is enlarged. The situation worsens with gaseous cholecystitis, and is more common in males with diabetes.

Clinical symptoms in older people often do not correspond to the actual picture of inflammation. Especially with the development of gangrenous changes in the bladder wall. When the nerves die, a period of temporary well-being begins. Appointed additional research, for example, ultrasound. Ultrasound allows you to determine the presence of gases in the cavity formed by bacteria.

Sometimes the gallbladder becomes twisted and the blood supply is disrupted. The pain is constant and radiates to the back. Occurs more often in older, skinny women. The condition is accompanied by dyspepsia, mostly nausea and vomiting. There are cases when, after dissolving stones, it was possible to straighten the walls using electrophoresis with novocaine. Signs often resemble:

1. Pancreatitis.
2. Appendicitis.
3. Ulcer.
4. Liver abscess.
5. Pyelonephritis.
6. Pneumonia right side lungs.
7. Urolithiasis.
8. Pleurisy.

Differential diagnosis is required.

Complications of cholecystitis

In addition to the development of cholecystitis against the background of stones, the disease is accompanied by complications. For example, perforation (breakdown) of the wall of the gallbladder with the simultaneous onset of inflammation caused by the contents getting into neighboring organs. Paravesical abscess is more common, accompanied by a number of characteristic clinical signs:

• Chills.
• Temperature.
• Weakness.
• Cardiopalmus.
• The bladder is enlarged and sharp pain occurs on palpation.

Cholecystitis manifests complications in the form of cholangitis and reactive hepatitis. As a result, bilirubin is practically not excreted, and intestinal bacteria appear in hepatocyte cells. Blood from the portal vein is almost not filtered, poisoning the body. Most often found in bile:

• E. coli.
• Proteus.
• Klebsiella.
• Streptococci.
• Clostridia.
• Pseudomonas aeruginosa.

It turns out, mainly representatives of the facultative flora in full. Many microorganisms move into the liver. In a similar way, gallstones lead to intoxication of the body. Diagnosis of cholangitis is carried out according to the triad of Charcot criteria:

1. Fever with chills.
2. Slowly growing jaundice.
3. Pain in the right side.

include acute pancreatitis.

Empyema and dropsy

Complete blockage of the ducts causes dropsy. This happens after acute attack cholecystitis. The consistency of the bile changes sharply with inflammatory exudate, the bladder fills with bile, the walls become stretched and sharply thinner. It is typical that at the first manifestation of the disease there are no complaints. In case of relapses, patients complain of dull pain in the right hypochondrium. The swollen bladder is soft to the touch and moves slightly to the sides.

If an infection gets inside, pus accumulates. And dropsy develops into empyema. The symptoms resemble a systemic inflammatory response in form.

Cholangiolithiasis

On average, this complication is observed in 15% of cases in the population; in old age, the percentage increases to one third of the number of patients. The syndrome consists of the appearance. Cholesterols are formed exclusively in the bladder; the presence of similar ones outside the organ is explained by migrations (caused by any reasons). The condition is dangerous due to the possibility of blocking the duct completely with the development of obstructive jaundice:

1. Jaundiced skin.
2. Enlarged liver.
3. Urine the color of beer.
4. Colorless feces.

Older people periodically develop black pigment stones. The formation is accompanied by alcoholism, hemolysis or cirrhosis of the liver. Brown stones are the result of the activity of harmful bacteria.

The process develops in a third of cases of surgical intervention in the extrahepatic ducts. The relapse rate reaches 6.

Scar strictures

When scars heal, the process is disrupted. The causes of the phenomenon lie in the specific action of bile or the presence of infection. When a gallstone passes, the formation is mechanically capable of disrupting normal healing. Defects of this kind are divided into:

1. Secondary inflammation.
2. Consequence of sclerosing cholangitis.
3. Post-traumatic strictures (up to 97% of all cases).
4. Defects of biliary anastomoses.

Most accidental injuries relate to gastric surgery. When the gallbladder is removed, a complication develops in approximately 0.2% of cases. The defeat can be strong or weak. Accordingly, the level of stricture is classified as high or low. The degree of narrowing of the duct due to tissue proliferation is:

1. Full.
2. Incomplete.

Strictures are usually divided by length into:

1. Total (full length).
2. Subtotal (longer than 3 cm).
3. Common.
4. Limited (less than 1 cm).

Above the stricture, the walls of the ducts thicken, and below they are replaced by fibrous tissue. The key manifestation is obstructive jaundice (see above).

Secondary cirrhosis caused by bilirubin

The condition is caused by extrahepatic cholestasis, a condition of reduced bile flow into the duodenum that is independent of hepatocyte function. Develops as a consequence of cholecystitis or cicatricial strictures.

As a result of such a course of cholelithiasis, obstructive jaundice may occur. Absorption is impaired in the intestines fat-soluble vitamins. The liver and spleen are enlarged. The condition develops into liver (or kidney) failure syndrome.

Biliary fistulas

An underlying stone sometimes causes necrotic changes, and cholelithiasis is complicated by perforation of the bladder walls. Clinical picture does not reveal the defect. An indirect sign will be a sharp subsidence of pain (as a result of the release of the contents of the bladder through the resulting hole). Sometimes there is profuse vomiting of bile, along with which stones come out if the formations manage to squeeze through. Ingestion of infection from the intestines leads to inflammation.

Prevention

It turns out that the causes of cholelithiasis should be eliminated. Dealing with the consequences is too expensive.

Every third mature (after 40 years) woman and every fourth man is found to have an accumulation of stones (calculi) in the gall bladder. Such a common metabolic pathology - cholelithiasis (cholelithiasis, cholelithiasis) - is initially asymptomatic and only when the stones move, it provokes biliary colic. Despite the seriousness of the disease, surgery is advisable only for repeated pain attacks.

Causes

GSD is a metabolic disease associated with impaired synthesis of bilirubin, cholesterol and the accumulation of calcium salts in bile. The consistency of the secreted bile changes, it becomes thicker and settles on the walls of the gallbladder. Stone formation is promoted congestion in the gallbladder. Gradual calcification of sediments leads to the formation of dense formations (stones) different diameters: from a large number of small grains of sand to one large formation the size of a walnut.

Cholesterol formations are layered, round/oval in shape, 4–15 mm in diameter, usually located in the gallbladder. Pigment stones (the main part of which is bilirubin) are black, shiny, uniform in structure and small in size. Multiple clusters of them can be detected both in the bile ducts and in the bladder itself.

Calcium stones have a brown color of varying intensity (from light to dark) and an asymmetrical shape with characteristic spikes. In most cases, the stones have a mixed composition and look like a cluster of tens or hundreds of tiny formations of different shapes with angular edges. Factors that provoke stone formation in the gallbladder:

• eating disorder (irregular eating, fasting, overeating) and unhealthy diet (excessive consumption of fried/fatty foods);
• low physical activity, sedentary work;
• obesity, diabetes;
• taking oral contraceptive pills;
• gastrointestinal pathology (gastrointestinal duct dyskinesia, chronic cholecystitis, pancreatic diseases, intestinal and liver pathology);
• pregnancy;
• helminths;
• old age (the contractility of smooth muscles decreases physiologically).

Clinical picture of cholelithiasis

In most cases (60–80%), cholelithiasis is asymptomatic and is detected by ultrasound or x-ray. Stone carriers may not know about their disease for years and note only periodic heaviness/a feeling of fullness in the right hypochondrium and a temporary loss of appetite, until the first attack of biliary colic occurs - the stones enter the duct and clog it. It can be triggered by a festive feast or driving with shaking (by car on a dirt road, by bicycle).

Symptoms of cholelithiasis in women often occur after wearing shapewear, which disrupts blood flow and prevents the flow of bile. An attack of colic usually occurs suddenly, often in the evening or at night, and lasts from 20–30 minutes to 3–8 hours. Symptoms of biliary colic:

• sharp pain in the right hypochondrium with possible irradiation to the right arm and shoulder blade;
• increased sweating;
• belching;
• bloating;
• nausea, vomiting without relief;
• unstable stool (dyspeptic form);
• bitterness in the mouth.

Small stones usually pass independently through the ducts and, once in the duodenum, are subsequently excreted in the feces. Painful symptoms eliminate themselves, but this does not mean that the process of stone formation has stopped. But in only 50% of patients, exacerbation of cholelithiasis recurs in the next year.

An attack that lasts 12 hours or more indicates persistent blockage of the ducts and the development of acute cholecystitis. Often the temperature rises, mechanical jaundice is possible (yellowish spots on the palms and yellowness of the sclera), discoloration of stool (stool looks like white clay) and some darkening of the urine (excretion of bilirubin through the kidneys).

Complications

Patients with cholelithiasis are prone to the following painful conditions:

• cholangitis;
• pancreatitis;
• cholestasis - blockage of the common bile duct and complete cessation of bile outflow;
• acute cholecystitis;
• perforation of the bladder wall and the formation of peritonitis, abscess (in severe cases, a person develops toxic shock and the likelihood of death).

Diagnosis of cholelithiasis

If you suspect stones in the bile ducts and bladder, you should contact a gastroenterologist. The diagnostic complex includes:

• general blood test (signs of inflammation - leukocytosis, elevated ESR);
• biochemistry (high liver parameters);
• duodenal intubation;
• cholecystocholangiography - x-ray with a contrast agent administered orally or intravenously;
• retrograde cholangiopancreatography ( endoscopic examination with the ability to remove small stones from the ducts);
• computed tomography with contrast injection.

How to treat gallstones?

Therapeutic tactics directly depend on the frequency of painful attacks and the patient’s condition. If biliary colic that occurs for the first time ends in successful passage of stones into the intestines, surgical intervention is not advisable. Radical measures are used only for persistent blockage of the bile duct ( emergency surgery), with a large number and large size of stones, with frequent repeated attacks, when the risk of severe complications increases 4 times.

Treatment without surgery

The fundamental part of non-surgical treatment is aimed at normalizing nutrition:

• 4 – 6 meals a day in small portions;
• exclusion of fatty/fried foods, smoked meats, hot spices, soda and chocolate;
• refusal of alcohol (often paroxysmal pain in the liver area in men is triggered by alcohol consumption);
• emphasis in creating a diet on dairy and plant products (wheat bran is especially useful in restoring digestive function).

Drug therapy includes drugs that dissolve stones (their composition is dominated by chenodeoxycholic and ursodeoxycholic acids). However, effectiveness is observed only when single X-ray negative stones (mainly cholesterol) no larger than 2 cm in size are detected. The drugs are taken for up to 1.5 years, such treatment does not exclude stone formation in subsequent years. Some clinics perform contact dissolution - the introduction of a therapeutic agent directly into the cavity of the gallbladder.


Shock wave lithotripsy is the extracorporeal destruction of cholesterol stones of no more than 3 pieces and up to 3 cm in diameter. Fragments of crushed stones with a diameter of 1 - 2 mm are painlessly excreted in the feces. The procedure is performed on an outpatient basis and requires high-tech equipment in the clinic. Within 5 years after lithotripsy, half of the patients are diagnosed with a relapse of the disease if the patient has not revised his diet and metabolic processes remain at the same level.

There are many ways to remove stones using folk remedies: decoction of birch leaves, beet syrup, infusion of dill seeds, sauerkraut juice, etc. However, it should be remembered that treatment with home remedies:

• requires a long time to achieve the effect;
• some recipes are dangerous in terms of exacerbation of the disease and the beginning of the movement of large stones, which is fraught with acute symptoms;
• is used only as a supplement to medical prescriptions and must be discussed with the treating gastroenterologist.

Surgery

The standard for radical treatment of cholelithiasis is cholecystectomy - excision of the gallbladder. Open cholecystectomy (resection through a large incision abdominal wall) is inferior to laparoscopic surgery (surgical manipulations are performed through 4 punctures or through 1 puncture in the navel area). The latter operation is easier to tolerate recovery period after it it lasts less, the cosmetic effect (lack of long scars) is also of considerable importance. Contraindications to laparoscopic cholecystectomy are limited to suspicion of peritonitis.

Prevention

To avoid stone formation in the gallbladder, you must follow the basic rules of a healthy lifestyle:

• Balance your diet and avoid overeating.
• Quit alcohol and smoking.
• Lead an active lifestyle (do small stretches during sedentary work).
• Treat diseases of the digestive tract.

Or cholelithiasis– a disease of the gallbladder, accompanied by the formation of stones in its cavity or bile ducts. It is generally asymptomatic or accompanied by a variety of clinical manifestations.

Gallstone disease is widespread throughout the world and occupies a leading place among other pathologies of the human digestive system. There is a clear differentiation of the disease by gender - women are affected 2 times more than men. Moreover, mothers with many children more often suffer from stones in the gallbladder or its ducts, which arise due to insufficient emptying of bile in the last trimesters of pregnancy. In 1/3 of multiparous women, characteristic symptoms of the disease are detected.

Classification of cholelithiasis

Depending on the location, size and localization of gallstones, the activity of inflammation and the condition of the biliary tract, three stages of gallstone disease are distinguished:

1) Initial (physiochemical) – pre-stone stage, characterized by changes in the composition of bile.
2) Asymptomatic stone carriers - the presence of stones in the gallbladder that do not manifest any complications or symptoms.
3) Clinical manifestations of the disease, indicating the development of a chronic or acute form of inflammation of the gallbladder.

In some cases, the fourth stage of gallstone disease is included, accompanied by the development of associated complications.

Causes of stone formation

The pathogenesis of stone formation in the gall bladder is still not precisely known, but it has been established that the key factor is a violation of the enterohepatic circulation mechanism bile acids and cholesterol. Its violation occurs for a number of reasons:

1. A disorder in the process of bile secretion, leading to its oversaturation with cholesterol, thickening and the formation of crystals.
2. Lack of bile outflow, resulting from obstruction of the bile ducts, valves: Oddi, pancreatic and bile ducts, small intestine, which is combined with impaired intestinal motility.
3. Changes in intestinal microflora associated with excessive reproduction and accumulation of bacteria in the ileum, with a subsequent increase in pressure in the duodenum.
4. Disorder of the digestion process and absorption of nutrients, creating the prerequisites for the development of biliary pancreatitis.

An important factor influencing the course of gallstone disease is hereditary predisposition, advanced age, diabetes, unhealthy diet, medication, obesity, pregnancy, inflammatory bowel disease, physical inactivity, rapid weight loss, chronic constipation, etc.

Types of gallstones

According to their composition, which directly depends on what part of the bile precipitates and crystallizes, several types of stones are distinguished:

homogeneous– pigment (bilirubin), cholesterol and calcareous;
mixed– the core consists of an organic compound, and the shell consists of layers of bile pigment, calcium salts and cholesterol (up to 80% of all stones);
complex– the core contains cholesterol, shells of calcium, bilirubin, cholesterol (10% of cases).

Most often, stones form in the gallbladder, less often in the hepatic and bile ducts, intrahepatic bile ducts.

Complications of gallstone disease

Incorrectly chosen treatment tactics for gallstone disease often leads to the occurrence of diseases such as:

Acute cholecystitis;
obstructive jaundice;
choledocholithiasis;
cholangitis;
chronic pancreatitis.

Cholecystectomy, an operation to remove the gallbladder, can also be complicated by postcholecystectomy syndrome, which worsens the patient’s quality of life. Clinical manifestations of the syndrome include abdominal pain, bitterness in the mouth, diarrhea, nausea, bloating, and increased body temperature. Sometimes patients experience yellowing of the skin and sclera of the eyes.

Symptoms of gallstone disease

In most patients, gallstone disease occurs without any symptoms. Only 1-2% develop the following symptoms: pressing, stabbing or cramping pain, radiating to the right shoulder or shoulder blade, in which a person cannot find a comfortable position to relieve them. A painful attack lasts on average 15-30 minutes, sometimes 3-4 hours, after which patients are left with discomfort in the abdominal area. In some patients, attacks of pain are accompanied by nausea, and even less often by vomiting green or yellow bile.

Diagnosis of gallstone disease

When diagnosing the disease, instrumental methods and a physical examination of the patient are used, including:

1. Medical examination of the patient to identify characteristic symptoms diseases of the gallbladder, tension and soreness of the skin in the abdominal area, presence on the skin yellow spots, general yellowness of the skin and sclera of the eyes. At the same time, the medical history is studied
2. Biochemical blood test to determine elevated levels of cholesterol, bilirubin, alkaline phosphatase, alanine or aspartic aminotransferases in her serum.
3. Conducting a general blood test to determine the number of ESR and leukocytes, indicating the presence of nonspecific inflammation in the body.
4. The use of cholecystography to detect an enlarged gallbladder and the presence of calcareous deposits on its walls.
5. Ultrasound examination of the abdominal cavity to detect stones in the gall bladder, obtain additional information about the condition of the bile ducts, liver, pancreas.
6. Performing a survey radiograph of the abdominal organs or cholangiography: endoscopic retrograde, magnetic resonance, percutaneous transhepatic or intraoperative, if there is a suspicion of the presence of stones in the bile ducts.

If ultrasound results are negative, microscopic examination of bile collected during endoscopy is used. The detection of cholesterol crystals in it indicates the presence of stones in the gallbladder or its ducts. The presence of pigment granules is not the same important factor in the diagnosis of gallstone disease.

Treatment of gallstone disease

Therapeutic treatment of gallstone disease is mainly aimed at reducing inflammation, improving the outflow of bile, normalizing the functioning of the gallbladder and its ducts, and correcting the patient’s hormonal levels:

1. Diet, balanced in the amount of vegetable fats and proteins. At the same time, patients are not recommended to eat high-calorie spicy and spicy foods containing high amounts of cholesterol and refined carbohydrates. To prevent acidity, dairy products are included in their menu, and flour products and cereal dishes are limited. Following a diet reduces the likelihood of gallbladder spasms, which can cause migration of sand and small stones. If the patient has an exacerbation of chronic pancreatitis, complete fasting and drinking water are prescribed, followed by split and frequent meals by the hour, excluding spicy, sour, smoked and fried foods.

2. Drug therapy. If the patient has contraindications for surgery or refuses surgery, medications containing bile salts are prescribed. The tablets must be taken orally as prescribed by your doctor. The effectiveness of treatment is 80-100% if the stones are round in shape, cholesterol in nature, size no more than 10 mm and have a smooth surface. However, such therapy is not recommended if the patient has large pigment stones with a diameter of more than 20 mm, as well as frequent and severe attacks of biliary pain.

By agreement with the patient, a single dose of ursodeoxycholic acid (Ursosan) is prescribed. daily dose up to 900 mg. Side effects are quite rare and account for only 5%. The medicine is taken until the stones are completely dissolved for up to 12 months and continues to be used for 3 months to prevent relapse.

When cholelithiasis is complicated by attacks of cholecystitis and disturbances of intestinal microflora, it is used antibacterial therapy. Medicines such as ciprofloxacin, cefuroxime, cefotaxime, imipenem are used in combination with antibacterial drugs: tetracycline, rifampicin, isoniazid. The use of probiotics that stimulate the growth of intestinal microflora is mandatory. To normalize digestion and absorption of nutrients, buffer antacids and enzyme preparations are prescribed.

Every ten years, the number of people suffering from gallstone disease doubles.
- 25% of women and 10% of men living in the northwestern regions of Russia have gallstones.
- 25% of women aged 40 suffer from gallstone disease.
- 50% of people over the age of 70 are diagnosed with gallstone disease.
- Gallstone disease is most often observed in children who have reached school age.

3. Surgical intervention (laparoscopic or open cholecystectomy) - indicated for symptoms of acute or chronic cholecystitis, stones in the common bile duct and gallbladder, occupying more than 2/3 of its volume. Relative indications for removal of the gallbladder along with stones are considered to be such diseases as: peritonitis, acute cholangitis, morbid obesity, jaundice, cirrhosis of the liver, bile fistulas, acute pancreatitis, pregnancy, acute cholecystitis with a disease duration of more than 48 hours.

In some countries, extracorporeal shock wave lithotripsy is used to crush stones. Small fragments of stones are dissolved using litholytic therapy, which involves oral administration of bile acids.

Prevention of gallstone disease

Research shows that a healthy lifestyle is one of the main principles of preventing gallstone disease:

Systematic physical activity;
limiting alcohol consumption and smoking;
correct and balanced diet, including proteins, vegetable fats, green tea, ripe and sweet fruits, herbs, dried bread, boiled chicken, raw pureed vegetables.

It is necessary to eat regularly, at least 4-5 times a day, since less frequent meals contribute to the stagnation of bile, its thickening and the formation of stones. Long breaks (over 4 hours) between traditional breakfast, lunch and dinner should be supplemented by drinking tea, juice, compote or kefir. Fried foods, legumes, garlic, onions and radishes are completely excluded from the diet. It is recommended to prepare all dishes from stewed, baked or boiled foods.

Traditional methods of treating cholelithiasis

Traditional medicine offers various remedies for the treatment of gallstone disease. In particular, it is recommended to take freshly prepared juices of carrots, beets and lemon in combination with the consumption of kefir or cheese. Warm helps a lot mineral water, especially if there are no acute pain attacks, which is best taken within 2 months.

To prevent further exacerbation of the disease, rosehip is used, which helps dissolve gallstones. A warm decoction of its roots is consumed 3-4 times a day for a month. The treatment course with rose hips is repeated after 1-1.5 weeks.

There are extremely diverse folk recipes that help with severe pain in the gallbladder area, and combine honey and various herbs, such as lemon balm, buckthorn, immortelle, rose hips, and celandine. The strained herbal decoction is drunk warm with 1 teaspoon of honey. Treatment of gallstone disease using traditional methods should be carried out with the permission of the attending physician and only as additional therapeutic assistance.

Gallstone disease, which is also commonly defined as cholelithiasis or cholelithiasis, is a disease in which stones form in the gallbladder or bile ducts. Gallstone disease, the symptoms of which are observed in patients, as shown by the results of medical practice, is ineffective in treatment using conservative therapy and various types techniques, therefore the only way to cure the disease is surgery.

general description

Gallstone disease is a fairly common diagnosis, and the peculiarity is that susceptibility to it, as well as the causes that provoke its development, are quite difficult to track. The fact is that in most people, cholelithiasis occurs latently, that is, in a latent form without any special manifestations. In structure various diseases, which affect the digestive organs, cholelithiasis occupies a significant place precisely because of its prevalence.

Industrialized countries have statistics on this matter of about 15% incidence, and it can be noted that the prevalence directly depends on the age and gender of the patients. In particular, men suffer from this disease half as often as women. Every fifth of women aged 40 years or more experiences cholelithiasis, while men of the same age experience it in every tenth case. Up to 50 years of age, cholelithiasis is observed in about 11%, from 50 to 69 – up to 23%, from 70 years and more – up to 50%.

Let us dwell directly on the features of the course of the disease. The movement of bile along the biliary tract occurs due to the coordination of the functions of the gallbladder, liver, pancreas, bile duct and duodenum. Due to this, in turn, bile enters the intestines in a timely manner during the digestion process; in addition, it accumulates in the gallbladder. When bile stagnates and its composition changes, the process of stone formation begins, which is also facilitated by inflammatory processes in combination with motor-tonic disorders of bile secretion (that is, dyskinesia).

There are gallstones cholesterol (the vast majority, about 90% of the variants of gallstones), as well as stones pigment And mixed . Thus, due to the oversaturation of bile with cholesterol, the formation of cholesterol stones, its precipitation, and the formation of crystals occur. A disruption in the gallbladder of the motility leads to the fact that these crystals are not removed into the intestines, which ultimately leads to their gradual growth. Pigment stones (they are also called bilirubin stones) are formed during increased decay, which occurs with actual hemolytic anemia. As for mixed stones, they are a unique combination based on the processes of both forms. Such stones contain cholesterol, bilirubin and calcium, the process of their formation itself occurs as a result inflammatory diseases affecting the bile ducts and, in fact, the gallbladder.

As for the reasons that contribute to the formation of gallstones, the following are among them:

• unbalanced diet (in particular, if we are talking about the predominance of animal fats in it with simultaneous damage to vegetable fats);
• hormonal disorders(with weakening of the functions characteristic of the thyroid gland);
• sedentary lifestyle;
• disorders associated with fat metabolism, which intersect with weight gain;
• inflammation and other types of abnormalities that occur in the gallbladder;
• various types of liver damage;
• spinal injuries;
• pregnancy;
• starvation;
• heredity;
• spinal injuries;
• diseases of the small intestine, etc.

The factors that provoke the development of the disease we are considering are the following:

• helminthiases;
• (arising from alcohol consumption);
• biliary tract infections (chronic);
• chronic hemolysis;
• demographic aspects (relevance of the disease for residents of rural areas, as well as the Far East);
• elderly age.

Gallstone disease: classification

Based on the characteristics of the disease accepted today, the following classification is distinguished in accordance with the stages relevant to it:

• physico-chemical (initial) stage – or, as it is also called, the pre-stone stage. It is characterized by changes occurring in the composition of bile. There are no special clinical manifestations at this stage; detection of the disease at the initial stage is possible, for which a biochemical analysis of bile is used to determine the characteristics of its composition;
• formation of stones – stage, which is also defined as latent stone carriage. In this case, there are no symptoms of gallstone disease, but the use of instrumental diagnostic methods makes it possible to determine the presence of stones in the gallbladder;
• clinical manifestations - stage, the symptoms of which indicate the development of acute or chronic form calculous.

In some cases, a fourth stage is also distinguished, which consists of the development associated with the disease complications.

Gallstone disease: symptoms

Manifestations characteristic of cholelithiasis are determined based on the specific location and size of the stones formed. Based on the degree of severity relevant to inflammatory processes, as well as based on functional disorders, the severity of the manifestations of the disease, as well as the features of its course, are subject to change.

In case of cholelithiasis, a particularly pronounced pain symptom is noted (bilious or) - this is sharp pain which suddenly appears in the area of ​​the right hypochondrium. It can be piercing or cutting in nature. After a few hours, the final concentration of pain is concentrated within the projection of the gallbladder. It is also possible for pain to radiate to the right shoulder, neck, right shoulder blade or back. In some cases, the pain radiates to the heart, which provokes the appearance.

Pain mainly occurs due to the consumption of spicy, fatty, fried or spicy foods and alcohol, against the background of severe stress or significant physical activity. Also, prolonged stay in an inclined position during work can provoke pain. The pain syndrome is caused by a spasm that forms in the area of ​​the muscles and ducts of the gallbladder, which is a reflex response to the irritation experienced by the wall due to the stones.

In addition, the cause of spasm is overstretching of the bladder, formed by excess bile, which occurs as a result of obstruction (blockage) that occurs in the biliary tract. For global, in the presence of blockage in the bile duct, the characteristic manifestations are dilation bile ducts liver, as well as an increase in the organ’s volume, resulting in a corresponding pain reaction of the pain capsule. The pain in this case is constant, often in the right hypochondrium there is a characteristic feeling of heaviness.

Nausea is also identified as accompanying symptoms, which may be accompanied in some cases by vomiting without proper relief after it. It is noteworthy that vomiting is also a reflex response to irritation. In this case, the capture of pancreatic tissue by the inflammatory process is a factor leading to increased vomiting, which in this case is indomitable and is accompanied by the release of bile with vomit.

Based on the severity of intoxication, there may be elevated temperature, fluctuating in subfebrile levels, but in some cases reaching severe fever. Blockage of the bile duct by a stone in combination with sphincter obstruction leads to discoloration of stool and jaundice.

Late diagnosis of the disease often indicates the presence of empyema (accumulation of pus) in the wall of the gallbladder, which arose due to the closure of the bile ducts by a calculus. Vesicoduodenal fistulas and biliary fistulas may also develop.

Diagnosis of cholelithiasis

Identification of symptoms characteristic of hepatic colic requires consultation with a specialist. The physical examination carried out by him means identifying symptoms characteristic of the presence of stones in the gallbladder (Murphy, Ortner, Zakharyin). In addition, a certain tension and soreness of the skin is detected in the area of ​​the abdominal wall muscles within the projection of the gallbladder. The presence of xanthomas (yellow spots on the skin formed against the background of a disorder in the body's lipid metabolism) is also noted, and yellowness of the skin and sclera is noted.

The results of the test determine the presence of signs indicating nonspecific inflammation at the stage of clinical exacerbation, which in particular consist of a moderate increase and leukocytosis. When hypercholesterolemia is determined, as well as hyperbilirubinemia and increased activity, characteristic of alkaline phosphatase.

Cholecystography, used as a method for diagnosing cholelithiasis, determines the enlargement of the gallbladder, as well as the presence of calcareous inclusions in the walls. In addition, in this case, the stones with lime inside are clearly visible.

The most informative method, which is also the most common in the study of the area of ​​interest to us and for the disease in particular, is. When examining the abdominal cavity in this case, accuracy is ensured regarding the identification of the presence of certain echo-proof formations in the form of stones in combination with pathological deformations to which the walls of the bladder are exposed during the disease, as well as with changes that are relevant in its motility. Signs indicating cholecystitis are also clearly visible on ultrasound.

Visualization of the gallbladder and ducts can also be performed using MRI and CT techniques for this purpose in specifically indicated areas. Scintigraphy, as well as endoscopic retrograde cholangiopancreatography, can be used as an informative method indicating disturbances in the processes of bile circulation.

Treatment of cholelithiasis

Patients diagnosed with cholelithiasis are prescribed a general hygienic regime, balanced nutrition, as well as systematic exercise in dosed volumes. Diet No. 5 is also indicated when certain foods are excluded (fats in particular). It is recommended to eat food “by the hour”. In general, the absence of complications often excludes the use specific treatment– in this case, first of all, the emphasis is on wait-and-see tactics.

With the development of acute or chronic forms of calculous cholecystitis, removal of the gallbladder is required, which in this case causes the process of stone formation. The specificity of surgical intervention is determined based on the general condition of the body and associated pathological process changes concentrated in the area of ​​the walls of the bladder and the tissues surrounding it, the size of the stones is also taken into account.

If symptoms relevant to cholelithiasis occur, you should contact a gastroenterologist; in addition, a consultation with a surgeon may be prescribed.