Innovative insights into gallstones

Gallstone disease (GSD) is a pathological condition characterized by a disorder of cholesterol or bilirubin metabolism in the body, which provokes the formation of solid inclusions in the gallbladder and bile ducts. According to statistics, the disease occurs in 10-20% of the adult population. According to a number of studies^[1]The disease develops two to three times more often in women than in men. In the latter, pathology is usually detected after 50-60 years, in women – in the menopause.

The provoking factors

There are risk factors that do not directly lead to the disease, but increase the likelihood of its occurrence. These include:

1. Nutrition is one of the main factors. A large amount of fatty, spicy and salty foods, rare snacks or overeating lead to a change in the viscosity of bile. It violates the ratio of the main components and increases the amount of cholesterol. As a result, a precipitate is formed, which gradually accumulates and forms seals of various shapes and sizes.
2. Age. The risk of developing cholelithiasis increases after age 40.
3. Emotional tension or stress has a negative impact on the body as a whole and many of its functions. Against this background, various diseases can develop, including cholelithiasis.
4. Diseases that disrupt bile metabolism (for example, Crohn’s disease, cirrhosis of the liver).
5. Heredity. If someone in your family has had cholelithiasis, you are more likely to have stones.
6. Lack of physical activity.
7. Congenital anomalies of the gallbladder that prevent its normal functioning.

Symptoms

Most often, at first, the presence of stones in the gallbladder does not cause any symptoms at all, and if they are found, it often turns out to be an accidental diagnostic finding. The main manifestation of cholelithiasis is biliary colic. It occurs, as a rule, when stones from the gallbladder enter the bile ducts, stretch the walls and clog them. Pain occurs when a stone obstructs the flow of bile, which increases pressure in the gallbladder or ducts. Colic is expressed by acute pain in the right hypochondrium or in the pit of the stomach, which can also spread to the back, to the right half of the chest. Often, the patient may feel bitterness in the mouth, nausea and flatulence (excessive accumulation of gases in the intestines), vomiting attacks that do not bring relief, and stool retention are also possible.

In some cases, small stones bypass the ducts and fall into the duodenum. Then the attack stops, and the stone leaves the body on its own. However, this happens infrequently, so a doctor’s consultation with the subsequent provision of qualified medical care can be vital.

When the outflow of bile is impaired, some patients may have a fever and there is a risk of developing complications: acute cholecystitis (inflammation of the gallbladder) and cholangitis (inflammation of the bile ducts), as well as inflammation in other organs of the gastrointestinal tract, such as the pancreas. For example, obstructive jaundice may appear.

Diagnostics

If you see a doctor in time, you can avoid the development of life-threatening conditions. When making a diagnosis, he conducts a survey and examination of the patient, collects an anamnesis. As a rule, first of all, an ultrasound examination (ultrasound) is performed to diagnose cholelithiasis. If ultrasound is performed by a qualified specialist, additional examinations are usually not required. Based on the data obtained, he can determine the location, size, number, nature of stones and analyze the effect of drug therapy, as well as give recommendations to the surgeon about the state of the gallbladder and ducts for planning surgical treatment.

As a clarifying method, magnetic resonance imaging (MRI) of the biliary tract can be additionally prescribed. MRI allows you to get layered images that provide comprehensive information about the anatomy of the biliary system and the liver as a whole, the structure of the bladder itself and its ducts.

However, both ultrasound and MRI are often not informative enough when small stones enter the ducts, which cause discomfort, and can also lead to the development of serious complications, such as jaundice and acute pancreatitis.

In world practice, the standard for examining patients with suspected cholelithiasis and stones in the bile ducts is endoscopic ultrasonography. This is an endoscopic examination, which differs from gastroscopy in that an ultrasonic sensor is located at the distal end of the endoscope, which allows you to most accurately examine this anatomical zone.

Laboratory tests, such as a complete and biochemical blood test, may indicate the presence of inflammation and jaundice, and therefore are mandatory in such patients.

Treatment

The gold standard of treatment for gallstone disease is laparoscopic surgery to remove the gallbladder (cholecystectomy). It can be performed in a planned manner (with a high risk of complications) or urgently (if they have already occurred). The gallbladder is removed through several small (no more than 1 cm) punctures in the abdominal wall using endoscopic equipment. This method rarely leads to the development of postoperative complications and leaves completely invisible scars. The complication rate of this method is low and does not exceed 1-4%.

Open cholecystectomy through an incision of the anterior abdominal wall is performed in clinics where there is no necessary equipment, as well as qualified specialists. An indication for open surgery is the impossibility of laparoscopic removal, for example, due to the large size of stones, adhesions in the abdominal organs or during emergency interventions, in case of a life threat. Such an operation is also performed under general anesthesia, but it is more traumatic and the rehabilitation period after it is quite long, the likelihood of complications is higher compared to laparoscopic surgery.

There are also cases when the patient’s condition does not allow the operation. For example, due to the patient’s advanced age, multiple concomitant diseases or malignant neoplasms, a high risk of complications associated with both the disease itself and surgical intervention.

In such cases, it is necessary to use methods of emergency care for patients to prevent the development of life-threatening conditions, such as sepsis. These methods can serve either as a definitive treatment or as a temporary treatment until the patient is stable enough to undergo gallbladder surgery. Let’s consider these methods in more detail.

Percutaneous cholecystostomy

It is the standard method for draining the gallbladder. This is a minimally invasive operation, during which, using a long thin needle, drainage is inserted into the lumen of the gallbladder under ultrasound or X-ray control through a puncture of the abdominal wall. Such an operation is temporary, its purpose is to relieve an acute condition in order to stop complications (for example, obstructive jaundice, cholangitis and acute cholecystitis). With its help, the pressure in the biliary tract is reduced and the outflow of excess bile is ensured, in addition to antibiotic therapy, the symptoms of inflammation – cholecystitis and cholangitis – are removed.

According to a study^[2], which was conducted by the American Society for Gastrointestinal Endoscopy, the overall technical and clinical success was 98% and 90%, respectively. In 3,7% of cases, such drainage causes complications. Also, it is important to note that up to 12% of patients experienced long-term adverse events associated with the external drainage catheter. Among them are such as pneumothorax and bleeding, which in themselves can be quite dangerous and traumatic. Premature prolapse or displacement of the catheter may also occur. The catheter itself is a foreign body that causes discomfort to the patient.

Endoscopic drainage of the gallbladder

This is an innovative minimally invasive drainage technique that has been developed quite recently. Its use became possible after the launch of a high-tech device on the market – a specially designed stent HOT AXIOS, which, under the control of endoscopic ultrasonography, is inserted into the gallbladder through the wall of the stomach or duodenum. The procedure allows you to remove the symptoms of acute cholecystitis, restore the patency of the biliary tract.

Recently, several endoscopic alternatives have been developed, and endoscopic ultrasound gallbladder drainage with stent implantation, which restores the flow of bile and stones from the gallbladder, is gaining popularity over percutaneous transhepatic cholecystostomy. This method has advantages over percutaneous and other methods: there is no external catheter, which is a source of discomfort for the patient, the operation is performed under intravenous sedation, the time of the intervention itself does not exceed 20 minutes, due to the characteristics of the stent, it is possible to ensure not only the outflow of bile, but also the removal of stones from bubble lumen. Also, if the patient is aggravated by comorbidities, this type of drainage can be an alternative to gallbladder removal, but it is often used as a temporary remedy to create the most comfortable conditions for delayed cholecystectomy.

Prevention

Acute cholecystitis rarely occurs spontaneously. In most cases, patients are aware of the presence of stones in the bile duct, but for various reasons, they delay performing cholecystectomy. If signs of acute cholecystitis appear, active treatment is necessary, so you should immediately consult a competent doctor. In no case should you self-medicate and use any medications on your own. Self-treatment can lead to a decrease in the intensity of symptoms and an uncritical attitude of the patient to his condition, which can lead to the development of dangerous complications that may not be recognized in time and significantly worsen the patient’s condition and prognosis for the treatment of the disease.

As part of prevention, it is recommended that after 40 years of age, periodic ultrasound diagnostics (ultrasound) of the abdominal organs be performed in order not to miss the formation of stones in the gallbladder. It is also recommended to adhere to general wellness measures – maintain an optimal weight, be physically active, eat balanced and regularly.

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