Contents
Cholelithiasis – a fairly common pathology, which affects about 10% of the adult population in Russia, Western Europe and the United States, and in the age group over 70 years this figure reaches 30%. It occurs mainly in industrialized countries, where people consume large quantities of food rich in animal proteins and fats. According to statistics, cholelithiasis is diagnosed in women 3-8 times more often than in men.
The gallbladder is an organ adjacent to the liver and acts as a reservoir for storing bile, which is produced by the liver. Bile is necessary for the proper digestion of food and has a complex composition. Its main components are cholesterol and bilirubin (a pigment produced by the liver). The main causes of cholelithiasis include an increased content of cholesterol in the composition of bile, violations of its outflow and stagnation, as well as infection of the gallbladder.
With prolonged stagnation of bile, cholesterol precipitates, which gradually leads to the formation of microscopic elements (“sand”), which eventually increase in size and combine into larger formations (calculi).
The size of gallstones varies over a very wide range, from a few millimeters to several centimeters. In some cases, one stone can occupy the entire cavity of the distended gallbladder. Stones with a diameter of 1-2 mm can pass through the bile ducts, the presence of larger stones leads to the appearance of clinical signs of cholelithiasis.
In most cases, the disease is asymptomatic, but when there are pronounced clinical manifestations, it is often necessary to resort to emergency measures.
Typical symptoms of gallstone disease include sudden attacks of biliary (hepatic) colic, which are accompanied by pain in the right hypochondrium, nausea, heartburn, vomiting, bloating, fever, signs of jaundice.
Prolonged course of the disease leads to narrowing of the bile ducts, infection of the gallbladder and the development of chronic inflammatory processes (cholecystitis, hepatitis, pancreatitis, duodenitis).
To date, there are the following methods of treatment of GSD:
Non-surgical stone removal:
Dissolution of drugs;
Remote ultrasonic lithotripsy;
Removal with minimal invasiveness:
Crushing stones with a laser;
Contact chemical litholysis;
Surgical intervention:
Laparoscopic removal of stones from the gallbladder;
Endoscopic cholecystectomy;
Open cavity operation.
The current standard of care for patients with gallstone disease is as follows:
When stones are found, their composition is analyzed. According to the chemical composition, cholesterol, lime, pigment and mixed stones are distinguished. They try to dissolve cholesterol stones with the help of bile acid preparations (ursodeoxycholic and chenodeoxycholic). A more radical method is the crushing of stones using ultrasound or a laser and the subsequent dissolution of their small particles and “sand” with acids.
However, the main treatment for gallstone disease is still cholecystectomy (removal of the gallbladder along with stones). At the same time, abdominal operations are gradually giving way to endoscopic removal.
Medical dissolution of stones
Only cholesterol stones with a diameter of up to 2 cm can be dissolved (this method does not work on calcareous and pigment stones). For this purpose, analogues of bile acids Ursosan, Henofalk, Urofalk, Henohol, etc. are used.
In parallel, stimulation of the contractile function of the gallbladder and bile production can be carried out with the help of Allochol, Holosas, Zixorin, Liobil.
Contraindications:
Various concomitant diseases of the gastrointestinal tract (ulcer, gastritis) and kidneys;
Taking oral contraceptives containing estrogens;
Obesity;
Pregnancy.
Disadvantages:
High recurrence rate (10-70%), since after stopping the drugs, the level of cholesterol in the bile rises again;
Long duration of treatment (from 6 months to 3 years);
Side effects such as diarrhea (10% of cases), changes in liver tests (ALT and AST);
The high cost of drugs.
crushing stones with ultrasound
This method is based on crushing stones under the influence of high pressure and vibration of a regenerated shock wave. Ultrasound destroys stones and crushes them into smaller particles with sizes not exceeding 3 mm, which are subsequently excreted through the bile ducts into the duodenum. Ultrasonic lithotripsy is suitable for patients who have a small amount (up to 4 pieces) of rather large cholesterol stones (up to 3 cm in diameter), without lime impurities in their composition.
Contraindications:
Blood clotting disorders;
Chronic inflammatory diseases of the gastrointestinal tract (cholecystitis, pancreatitis, ulcer);
Pregnancy.
Disadvantages:
Possible blockage of the bile ducts as a result of vibration;
Damage to the walls of the gallbladder with sharp edges of stone fragments.
Crushing stones with a laser
Access to the gallbladder is through a puncture in the anterior abdominal wall. The laser beam is brought directly into the impact zone and splits the existing stones. The duration of the procedure is no more than 20 minutes.
Contraindications:
The patient’s weight exceeds 120 kg;
Age over 60;
Severe general condition.
Disadvantages:
The likelihood of a burn of the mucous membrane, which in the future can lead to the development of an ulcer;
Injury to the walls of the gallbladder with sharp edges of stones and obstruction of the bile ducts;
The need for special equipment.
Contact chemical cholelitholysis
This method was developed as part of the current trend in the development of organ-preserving methods of treatment. With its help, not only cholesterol stones are dissolved, but also any other types of stones. The size and number of stones also do not matter. This method can be used at any stage of the disease, and, unlike the two previous ones, not only in the asymptomatic course of the disease, but also in the presence of its pronounced clinical signs.
Its essence is as follows: a thin catheter is inserted into the gallbladder through the skin and liver under ultrasound control, through which a special drug dissolving stones is dripped. The efficiency of the method is 90%.
Methyl tert-butyl ether, which is a strong organic solvent, is usually used as the drug. It has been proven that the gallbladder is resistant to the cytotoxic effect of methyl tert-butyl ether.
Disadvantage of the method — Invasiveness.
Laparoscopy
Laparoscopy is performed under general anesthesia. Stones are removed using trocars (metal guides) that are inserted into incisions in the abdomen. The peritoneum is filled with carbon dioxide, a tube of the apparatus is inserted into one of the incisions to transfer the image to the monitor screen. Focusing on the image, the doctor finds and removes the stones. After the end of the operation, staples are applied to the ducts and vessels of the gallbladder. The duration of the operation is about an hour, the hospital stay is 1 week.
The indication for laparoscopy is calculous cholecystitis.
Contraindications:
Obesity;
Too large stones;
The presence of adhesions after surgical interventions;
gallbladder abscess,
Diseases of the heart and respiratory system.
Cholecystectomy
Both laparoscopy and laparotomy mean in this case the removal of the gallbladder itself. Surgical treatment is indicated for large stones and frequent relapses, which are accompanied by severe pain attacks, high fever and various complications.
Laparoscopic cholecystectomy
During laparoscopic cholecystectomy, gallstones are removed along with the bladder through a small incision up to 1,5 cm in diameter on the anterior surface of the abdomen. In total, 3-4 such incisions are performed. Through another incision, a laparoscope (a small tube with a video camera) is inserted to monitor the operation. The advantages of laparoscopy over abdominal surgery are a short recovery period, no visible scars, and lower cost.
open surgery
Open cholecystectomy is performed in the presence of very large stones in the gallbladder, as well as in various complications of cholelithiasis and inflammatory processes in the internal organs. In open surgery, the gallbladder is removed through a 15-30 cm incision that runs from the right hypochondrium to the navel.
Disadvantages:
High degree of invasiveness;
The need for anesthesia;
Risk of internal bleeding or infection; Possibility of death in case of emergency surgery.
Why can’t the gallbladder be removed?
Removal of the gallbladder leads to a chain of biochemical changes, during which the regulation of bile flow is lost. Motility of the muscles of the duodenum is disturbed, bile acquires a more liquid consistency and weakly protects the organ from pathogenic microorganisms that begin to multiply, destroying the normal microflora of the digestive organs. As a result, bile acids strongly irritate the mucous membranes, which can lead to duodenitis (inflammation of the duodenum), as well as gastritis, esophagitis (inflammation of the intestinal mucosa), enteritis (inflammation of the small intestine), and colitis.
Additionally, secondary absorption disorders occur: bile is usually used 5-6 times, making turns between the liver and intestines, and in the absence of the gallbladder, bile acids are quickly excreted, which negatively affects the digestion process.
After cholecystectomy, patients often complain that pain in the right hypochondrium and in the liver region persists, bitterness in the mouth often appears, food has a metallic taste.
Surgery does not eliminate the symptoms of gallstone disease. Stones after removal of the gallbladder can form in the bile ducts, and so-called choledocholithiasis occurs.
The bladder is removed due to the formation of stones in it, the cause of which is a pathological change in the chemical composition of bile, and after the operation this reason remains. The secretion of “bad” stone-forming bile continues, the amount of which increases, which has a negative impact not only on the state of the gastrointestinal tract, but also on other body systems.
Based on the foregoing, it can be concluded that non-invasive and minimally invasive methods can be used in the treatment of young people with the initial stages of the development of the disease, stones of small size and with no serious contraindications. However, in all other cases, it should be remembered that cholecystectomy is the last way out, and it should be resorted to when all other methods have been ineffective.
What is desirable to exclude from the diet?
The composition of the diet is of great importance in this disease.
With stones in the gallbladder, it is recommended to exclude the following foods and dishes from the menu:
Fatty meat (pork, lamb, beef) and fish;
Sausages, smoked meats, pickles;
Eggs;
Butter;
Legumes, radishes, radishes, eggplants, cucumbers, artichokes, asparagus, onions, garlic;
Fried, sour and spicy dishes;
Rich broths;
Coffee, cocoa and alcohol.
It is recommended to use foods that stimulate the excretion of excess cholesterol:
Buckwheat and oatmeal;
Fruits vegetables;
Milk and dairy products with a fat content of not more than 5%;
Lean meat and fish;
Compotes, fruit drinks, mineral water up to 2 liters per day.