gallstones
Introduction
Introduction to biliary stones Biliary stones are the most common diseases in the biliary system, including gallstones, common bile duct stones, and intrahepatic bile duct stones. It is generally associated with biliary infections (especially parasite infections). The accumulation of bile and the imbalance of cholesterol metabolism are the main causes of stones, and often form stones by various reasons. Pathologically, biliary stones consist of different cholesterol, bile pigments and calcium salts. Clinically more common in middle-aged women, mainly manifested in biliary colic in the right upper abdomen, due to the movement of gallstones in the tract to make the gallbladder or common bile duct smooth muscles dilate and paralyze and produce biliary colic. Biliary colic often has certain incentives such as a full meal or a shock in the abdomen. Single-port laparoscopic cholecystectomy is a common treatment in biliary calculi. Laparoscopic cholecystectomy is now preferred for patients undergoing cystectomy. basic knowledge The proportion of illness: 0.001% Susceptible people: no special people Mode of infection: non-infectious Complications: acute suppurative cholangitis acute biliary pancreatitis
Cause
Causes of biliary stones
Cause (80%):
Pathologically, biliary stones consist of different cholesterol, bile pigments and calcium salts. According to the different components of biliary stones, it can also be divided into cholesterol stones, mostly single round and large, smooth surface can be granular, the profile is radial, X-ray can be transmitted. The pigment stones are mostly multiple, small and have no certain shape. If it is a mixed stone, its center is mostly cholesterol (the parasite's residue or eggs can also form the core), forming a concentric layered shape, which can be single or multiple, and most of the large stones are located in the gallbladder, located in the bile duct stones. Most are small and can cause obstruction leading to bile duct dilatation or even infection. Gallstones often combine with cholecystitis.
Prevention
Biliary stone prevention
1. Diet regulation is the most ideal preventive method to prevent cholelithiasis and gallbladder cancer. Prevention of gallstones should pay attention to diet regulation, diet should be diverse, in addition, cold, greasy, high protein, irritating food and spirits and other easy to help heat and heat, so that cholestasis, should also eat less. Vegetables and fruits, fish and seafood that are rich in vitamin A and vitamin C help to clear the dampness, dissolve the stones, and eat more.
2. Life should be regular, pay attention to work and rest, often participate in sports activities, eat breakfast on time, avoid getting fat, reduce the number of pregnancies, etc. is also a very important preventive measure.
3. If the parents of the family have gallstones, they should pay attention to the relevant preventive medical examination.
Complication
Biliary stone complications Complications Acute suppurative cholangitis acute biliary pancreatitis
1. Acute suppurative cholangitis is the most common complication of primary bile duct stones. The clinical manifestations of primary bile duct stones are mostly related to it. Mainly manifested as right upper quadrant pain, chills and high fever and jaundice, common bacteria causing biliary infection are Gram-negative bacilli or anaerobic bacteria, Escherichia coli is more common, more often mixed infection. When the stone is incarcerated at the lower end of the bile duct, acute suppurative cholangitis appears. After the anti-inflammatory and antispasmodic treatment, the local inflammation and edema subsided, the stones floated, and the incarceration was relieved. The above symptoms and signs disappeared, thus showing volatility jaundice. B-ultrasound can be found in extrahepatic bile duct dilatation or bile duct stones; it can be found in laboratory such as leukocytosis. It is generally believed that acute suppurative cholangitis should be treated with anti-inflammatory, anti-inflammatory and choleretic rehydration treatments, and elective surgery should be performed after the symptoms are relieved. However, it should be closely observed during non-surgical treatment. Once acute obstructive suppurative cholangitis occurs, surgery should be considered.
2. Biliary liver abscess due to hepatic bile duct stones complicated infection can not be timely surgical drainage or intrahepatic small hepatic duct stones incarceration caused by suppurative small cholangitis, inflammation and surrounding tissue formation. Multiple small abscesses are more common. There may be pain in the right upper quadrant or abdominal pain. It is characterized by chills and high fever. It is a relaxation type, and jaundice is optional, and the course of disease is generally longer. The disease has not been effective after short-term non-surgical treatment, and the biliary tract should be drained by surgery. If it is a diffuse small abscess, the biliary tract can be drained. If there is a large abscess in addition to a single large abscess or multiple abscess, in addition to biliary drainage, abscess drainage should be performed at the same time.
3. Biliary hemorrhage is a serious complication of primary bile duct stones.
4. Biliary cirrhosis is a late complication of primary bile duct stones and belongs to advanced biliary tract disease. Severe with portal hypertension, splenomegaly and hypersplenism. In addition to the symptoms of hepatolithiasis, there are also manifestations of cirrhosis and portal hypertension. If the patient has no portal hypertension, biliary exploration should be performed as soon as possible to remove the intrahepatic stones as much as possible, and some patients' liver function is expected to recover. If it is accompanied by portal hypertension, the treatment is more complicated. The patient's condition allows one-stage biliary exploration and stone removal and splenectomy, and then complete hepatolithiasis operation to treat complex intrahepatic lesions. Otherwise, staged surgery should be performed. First, biliary exploration should be performed to remove stones, and portal hypertension should be performed again. Finally, complicated hepatobiliary surgery should be performed. These patients are seriously ill, difficult to handle, and have a high mortality rate. Sometimes the prognosis is extremely poor regardless of the operation. Therefore, it is best for the hepatolithiasis to perform surgery without symptoms or symptoms to reduce liver damage.
5. Cholangiocarcinoma Most scholars believe that the occurrence of cholangiocarcinoma is related to primary bile duct stones. In particular, intrahepatic bile duct stones and infected people have more intrahepatic cholangiocarcinoma, also known as cholangiocarcinoma. It is often masked by the symptoms of primary bile duct stones and is easily missed before surgery. Patients with primary bile duct stones have recently experienced frequent and exacerbated episodes of upper abdominal pain and are limited to a certain site. Abdominal examination of the right upper abdomen or xiphoid under the obvious tenderness, can still be awkward and tender mass, should be suspected of the disease. Further B-ultrasound and CT examination can simultaneously detect intrahepatic calculi and intrahepatic localized or diffuse space-occupying lesions, which can basically confirm the diagnosis. These patients are generally negative for AFP. Due to repeated inflammation and fibrosis of the bile duct stones, cholangiocarcinoma is mostly hard cancer, and there are more fibrous connective tissues. Mainly for local invasive growth, intrahepatic jumping metastasis and distant metastasis.
6. Biliary pancreatitis Primary bile duct stones with acute pancreatitis are much less than secondary bile duct stones, which may be related to the presence of Oddi sphincter relaxation in most patients with primary bile duct stones.
Symptom
Symptoms of biliary calculi Common symptoms Abdominal pain Obstructive jaundice biliary colic Skin sclera yellow stain
Clinically more common in middle-aged women, mainly manifested in biliary colic in the right upper abdomen, due to the movement of gallstones in the tract to make the gallbladder or common bile duct smooth muscles dilate and paralyze and produce biliary colic. Biliary colic often has certain incentives such as a full meal or a shock in the abdomen. Biliary colic usually has a progressively progressive pain in the upper abdomen or the upper right abdomen, often radiating to the right scapula or shoulder, with vomiting. Biliary colic can be intermittent. If the gallstone is incarcerated in the cystic duct, it will cause the gallbladder to expand. If the gallstone is located in the common bile duct opening or the common bile duct opening, it will cause obstructive jaundice. The clinical symptoms of intrahepatic bile duct stones are mild, with repeated abdominal pain, chills and fever, and occasional jaundice.
Examine
Examination of biliary stones
1. Flat film performance:
About 20% of biliary stones are impervious to X-rays. Therefore, single or multiple high-density shadows can be seen in the biliary region (the gallbladder region) in the abdominal plain film or the lower right abdomen. It can be large or small and has many forms. Variety, it can be a concentric layered circle, or it can be an irregular shape that gathers into a pile, or it can be a shape of several polyhedrons. When these signs are seen, the diagnosis of biliary stones can generally be made.
About 80% of biliary stones are X-ray permeable and generally not found on plain films.
2. Intravenous cholangiography:
Mainly to understand the biliary tract, gallbladder function and whether there are stones. The negative stones appear as round or square translucent shadows in the developed bile duct, especially the gallbladder filled with contrast agent. These signs are more typical, either single or multiple, and the gallstones in the gallbladder are in the developed gallbladder. Shows a grainy negative translucent shadow.
3.ERCP:
Can show X-ray negative stones, understand whether the location of the stones in the liver or in the extrahepatic bile duct, whether the stones completely block the bile duct, whether the intrahepatic bile duct expands and expands.
4. Ultrasound performance:
High echogenic light in the gallbladder or bile duct, accompanied by sound and shadow.
5.CT performance:
Because CT has a high resolution of tissue density, a clear diagnosis can be made for biliary stones. Whether it is intrahepatic calculi or extrahepatic calculi, most of the biliary stones in CT examination show high-density uniform or uneven shadows. Easy to identify. Gallbladder stones change the position and move.
6. MRI and MRCP examination:
For non-invasive biliary imaging, it shows the low signal intensity of the biliary system.
Diagnosis
Diagnosis and diagnosis of biliary calculi
Diagnosis of gallstones
Common bile duct stones: mostly located in the lower middle segment of the common bile duct. However, as the stones increase, increase and the common bile duct expands, stones accumulate or move up and down, often the hepatic duct is involved. Most patients have had one or more history of acute or chronic cholecystitis or a history of biliary tsutsugamushi in the past, and then jaundice after a severe biliary colic, indicating that the stone has entered the common bile duct, or has been embedded after formation in the common bile duct. Dun and blocked.
Primary common bile duct stones: a component of primary bile duct stones that can form in the common bile duct, or stones that originate in the intrahepatic bile duct fall into the common bile duct.
Secondary choledocholithiasis: refers to the stones that originate in the gallbladder descending through the cystic duct to the common bile duct.
Intrahepatic bile duct stones: simple intrahepatic bile duct stones, no acute inflammatory episodes, patients can be asymptomatic or only mild liver discomfort, dull pain, often found in B-ultrasound, CT and other examinations. Two-thirds to three-quarters of cases of intrahepatic bile duct stones coexist with hilar or extrahepatic bile duct stones, so the clinical manifestations of most cases are similar to extrahepatic bile duct stones.
Extrahepatic bile duct stones: can be originated in the bile duct system, or can be discharged from the gallbladder to the bile duct. Most patients with bile duct stones have biliary colic after the fat meal and postural changes. This is because the stones move downward in the bile duct, stimulate bile duct spasm, and block bile flow. Abdominal pain occurs mostly under the xiphoid process and the right upper abdomen. The paroxysmal severe knife-like colic is often radiated to the back of the right back shoulder, and there are gastrointestinal symptoms such as nausea and vomiting.
Differential diagnosis of gallstones
(1) Liver diseases: such as viral hepatitis, cirrhosis, etc.
(2) Gastrointestinal diseases: such as gastrointestinal dysfunction, peptic ulcer, high appendicitis and right colon disease.
(3) biliary tract diseases: such as biliary dysfunction, gallbladder tumors, gallbladder polypoid lesions and biliary parasites.
(4) Others: such as right pyelonephritis, herpes zoster and radiculitis.
Negative stones need to be differentiated from biliary tumors such as cholangiocarcinoma.
