| disease | Gallbladder Stones |
After the formation of stones in the gallbladder, they can irritate the gallbladder mucosa, not only causing chronic inflammation of the gallbladder but also leading to secondary infections when the stones become lodged in the neck of the gallbladder or the cystic duct, resulting in acute inflammation of the gallbladder. Due to the chronic irritation of the gallbladder mucosa by the stones, there is also a risk of gallbladder cancer, with reports indicating an incidence rate of 1-2%.
bubble_chart Clinical Manifestations
The symptoms of gallstones depend on the size and location of the stones, as well as the presence of obstruction or inflammation. Approximately 50% of patients with gallstones remain asymptomatic throughout their lives, known as silent stones. Larger gallstones can cause discomfort or fullness in the upper middle or right upper abdomen, belching, anorexia, and other dyspeptic symptoms, especially after consuming fatty foods. Smaller stones may obstruct the cystic duct after a heavy meal, consumption of fatty foods, or when lying flat at night, leading to biliary colicky pain and acute cholecystitis. Due to gallbladder contractions, smaller stones may pass through the cystic duct into the common bile duct, causing obstructive jaundice. Some stones may then be expelled into the duodenum, while others remain in the bile duct, forming secondary bile duct stones. Stones can also chronically obstruct the cystic duct without infection, resulting only in gallbladder hydrops, where a painlessly enlarged gallbladder may be palpable. In the absence of infection, gallstones typically show no specific signs or only grade I tenderness in the right upper abdomen. However, during acute infection, tenderness and muscle rigidity may appear in the upper middle and right upper abdomen, and a noticeably enlarged, tender gallbladder may sometimes be felt. Murphy's sign is often positive.
bubble_chart DiagnosisGallstones with a history of acute episodes are generally not difficult to diagnose based on clinical manifestations. However, if there is no history of acute episodes, the diagnosis mainly relies on auxiliary examinations. B-ultrasound can accurately diagnose gallstones by displaying hyperechoic masses within the gallbladder and their posterior acoustic shadows, with a diagnostic accuracy rate of up to 95%. Oral cholecystography can reveal the shadow of gallstones in the gallbladder. The discovery of bile sand or cholesterol crystals in the gallbladder bile (i.e., β bile) obtained during duodenal drainage aids in the diagnosis.
bubble_chart Treatment Measures
(1) Surgical Treatment: Perform cholecystectomy, which yields good therapeutic outcomes. Due to the possibility of concurrent secondary bile duct stones, the common bile duct should be explored during surgery if the following indications are present. Absolute indications for exploration: ① Palpable stones in the common bile duct; ② Manifestations of cholangitis and jaundice during surgery; ③ Intraoperative cholangiography reveals bile duct stones; dilation of the common bile duct with a diameter exceeding 12mm, though rare cases may show duct dilation without stones. The positive rate for common bile duct exploration under these conditions is only about 35%. Additionally, there are some relative indications for exploration: ① History of jaundice disease; ② Presence of small stones in the gallbladder; ③ Chronic atrophic changes in the gallbladder; ④ History of chronic recurrent pancreatitis.
(2) Litholytic Therapy: The primary mechanism of gallstone formation involves changes in the physicochemical composition of bile, a reduction in the bile acid pool, and an increase in cholesterol concentration. Experiments have shown that oral administration of chenodeoxycholic acid can expand the bile acid pool, reduce cholesterol secretion by the liver, and thereby convert cholesterol in the gallbladder bile into an unsaturated state, potentially dissolving and eliminating cholesterol stones in the gallbladder. In 1972, Danjinger first successfully used chenodeoxycholic acid to dissolve and eliminate cholesterol gallstones in four cases. However, this Yaodui has certain toxic reactions on the liver, such as elevated alanine aminotransferase levels, and may irritate the colon, causing diarrhea. Currently, the primary drugs for litholytic therapy are chenodeoxycholic acid and its derivative ursodeoxycholic acid. Treatment indications include: ① Gallstones with a diameter of less than 2cm; ② Gallstones that are X-ray translucent and low in calcium content; ③ Patent cystic duct, i.e., a functional gallbladder visible on oral cholecystography; ④ Normal liver function in the patient; ⑤ No significant history of chronic diarrhea. The treatment dose is 15mg/g daily, with a course lasting 6 to 24 months. The efficacy rate for stone dissolution generally ranges from 30% to 70%. During treatment, B-ultrasound or oral cholecystography should be performed every six months to monitor stone dissolution. Due to the high cost of these litholytic drugs, their side effects and toxic reactions, and the necessity for lifelong medication—since discontinuation for three months may lead to cholesterol in bile reverting to a supersaturated state and stone recurrence—statistics show a three-year recurrence rate of up to 25%. Currently, this litholytic therapy has certain limitations. Additionally, some newer drugs, such as Rowachol and metronidazole, also exhibit litholytic effects. Combining phenobarbital with chenodeoxycholic acid often enhances the litholytic effect. In 1985, reports emerged of percutaneous transhepatic gallbladder catheterization with infusion of mono-octanoin or methyl tert-butyl ether for direct gallbladder stone dissolution, achieving some therapeutic success.
The main indications for treating gallbladder stones with shock wave lithotripsy are cholesterol stones in the gallbladder, negative stones as shown by oral cholecystography, no more than 3 stones with a diameter of 12–15 mm, or only 1 stone with a diameter of 15–20 mm, along with normal gallbladder contraction function. Since January 1988, Zhongshan Hospital Affiliated with Shanghai Medical University has used the EDAP-LT 01 shock wave lithotripter to treat 687 cases of gallbladder stones, achieving a stone fragmentation rate of 98%. The disappearance rates of gallbladder stones at 1, 2, 3, 4, and 6 months after a single shock wave treatment were 27%, 33%, 40%, 45%, and 50%, respectively. The side effects after treatment were mild, such as dull pain and discomfort in the right upper abdomen (45%), biliary colicky pain (16%), and lack of strength. No complications involving damage to organs such as the liver, gallbladder, pancreas, or gastrointestinal tract were observed.
To improve the disappearance rate of crushed stones, ursodeoxycholic acid (UDCA) at a dose of 8mg/kg/d is administered before and after shock wave therapy to achieve a synergistic effect of stone fragmentation and dissolution. To consolidate the therapeutic effect after stone disappearance, UDCA can be continued for another six months. This method is safe and effective, but still has shortcomings such as a recurrence rate of approximately 11.2%, high treatment costs, and strict indications for therapy.
