Gallstone disease: symptoms and treatment in adults

The insidious gallstone disease usually does not betray its presence in the body when the process of "stone formation" is just beginning. It will take more than one year after the first pebble, invisible to the eye, appears in the gallbladder and before the person experiences a painful attack of gallstone disease for the first time.
Therefore, it is so important for everyone to know about the nature of the occurrence of cholelithiasis and the potential causes provoking it, because a warned person, as you know, is not unarmed.

Development mechanism

The initial process of gallstone formation is the formation of putty bile (biliary sludge). In 80-85% of cases, biliary sludge disappears, but most often comes back again. The reason for the appearance of biliary sludge is: pregnancy, taking hormonal drugs, a sharp decrease in body weight, etc.
But in some situations, taking medications is necessary, which is decided individually in each case. Gallstones are formed from the basic elements of bile. Normal bile secreted by hepatocytes, in an amount of 500-1000 ml per day, is a complex colloidal solution with a specific gravity of 1.01 g / cm³ containing up to 97% water. The dry bile residue consists primarily of bile salts, which ensure the stability of the colloidal state of bile, play a regulatory role in the secretion of its other elements, in particular cholesterol, and are almost completely absorbed in the intestine during enterohepatic circulation.
There are cholesterol, pigment, calcareous and mixed stones. Concrements, consisting of one component, are relatively rare. The vast majority of stones have a mixed composition with a predominance of cholesterol. They contain over 90% cholesterol, 2-3% calcium salts and 3-5% pigments, and bilirubin is usually located in the form of a small core in the center of the calculus. Stones with a predominance of pigments often contain a significant admixture of calcareous salts, and they are called pigment-calcareous.
The structure of the stones may be crystalline, fibrous, layered or amorphous. Often, one patient in the biliary tract contains calculi of various chemical composition and structure. The sizes of the stones vary greatly. Sometimes they are fine sand with particles less than a millimeter, in other cases, one stone can occupy the entire cavity of the enlarged gallbladder and weigh up to 60-80 g. The shape of gallstones is also diverse. They are spherical, ovoid, multifaceted (faceted), barrel-shaped, awl-shaped, etc.
To a certain extent, two types of stone formation in the biliary tract are conditionally distinguished:

    primary
    secondary

The formation of calculi in the unchanged biliary tract is the beginning of a pathological process that, for a long time or throughout life, may not cause significant functional disorders and clinical manifestations. Sometimes it causes impaired patency of various departments of the biliary system and the addition of a chronic, prone to exacerbation of the infectious process, and, consequently, the clinic of cholelithiasis and its complications.
Secondary stone formation occurs as a result of the fact that already during the cholelithiasis there are disturbances in the outflow of bile (cholestasis, biliary hypertension) due to obstruction by the primary stones of the “narrow” places of the biliary system (neck of the gallbladder, terminal part of the common bile duct), as well as secondary cicatricial stenosis, usually localized in the same places, which contributes to the development of ascending infection from the lumen of the gastrointestinal tract. If the main role in the formation of primary stones is played by violations of the composition and colloidal structure of bile, then secondary calculi are the result of cholestasis and the associated biliary system infection.
Primary stones form almost exclusively in the gall bladder, where bile under normal conditions stagnates for a long time and is brought to a high concentration. Secondary calculi, in addition to the bladder, can also form in the bile ducts, including intrahepatic.

The main causes and risk factors

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

    spinal injuries;
    pregnancy;
    starvation;
    heredity;
    spinal injuries;
    diabetes;
    unbalanced nutrition (in particular, when it comes to the predominance of animal fats in it with simultaneous damage to vegetable fats);
    hormonal disorders (with weakening of the functions inherent in the thyroid gland);
    sedentary lifestyle;
    disorders associated with fat metabolism, which intersects with an increase in body weight;
    inflammation and other abnormalities that occur in the gallbladder;
    various types of liver damage;
    diseases of the small intestine, etc.

As factors that provoke the development of the disease under consideration, we distinguish the following:

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

Types of stones

The stones are divided into four varieties, depending on the components.

    Cholesterol - as part of cholesterol.
    Bilirubin - formed by the coloring pigment bilirubin.
    Lime - created from calcium salts.
    Mixed - The above components are present in combination to which unprocessed protein can be added.

While the formations are small (and they come in from 0.1 mm), they calmly lie at the bottom of the gallbladder, and the owner does not even know about their existence. If a person is lucky, he will be able to feel bitterness, heaviness and nausea after eating at an early stage of stone formation, before they are overgrown with deposits, have not reached large sizes and have not moved into narrow channels, causing unbearable pain.

Developmental stages

From the very beginning of the onset of the disease to its specific manifestations, in the vast majority of cases, a very long time passes. Consider the main stages of gallstone disease, according to the accepted medical classification:

    The initial stage (docum). At this stage, with cholelithiasis in the bile, changes in composition are observed, which the patient cannot feel on his own. The doctor can trace these changes based on the results of a biochemical analysis of bile.
    Stage of formation of stones. A person cannot feel anything even at this stage of the disease, but the doctor can see the changes in the internal organs during the diagnosis.
    Stage of clinical manifestations. Only at this stage the patient appears pain indicating the presence of one form or another of the disease (acute or chronic). Pain with gallstone disease is quite characteristic and almost immediately the doctor may suspect this pathology.
    Stage of complications.

Symptoms of gallstone disease

Consider the signs of gallstone disease in humans. When it comes to gallstone disease, its symptoms experienced by the patient once, will never be forgotten. And all because in most cases the main signs of gallstone disease are associated with pain.
It is important to understand that for all to hear the disease will manifest itself only when enough calculi appear in the gallbladder or ducts that do not allow the outflow of bile. It is difficult for the patient to suspect a malfunction in the biliary system until this moment. In most cases, patients learn about the presence of this pathology only after an attack (biliary colic). Anyone who has ever experienced an attack of gallstone disease will remember the symptoms for a long time.
So what are the symptoms of gallstone disease in women (most often) and in men (much less often)? An attack of cholelithiasis is indicated by:

    pain under the right rib (it is especially severe in the first hour of an attack);
    sudden onset of an attack;
    nausea, accompanied by vomiting, after which it does not become easier.

It is characteristic that during biliary colic, body temperature almost never rises. But for diseases such as cholecystitis or cholangitis, it is just characteristic.

    Of course, the symptoms of gallstone disease directly depend on the stage of the disease, the degree of the inflammatory process, and specifically on the size of the gallstones and their location (the closer they are to the bile duct, the more pronounced the signs are).

When the doctor asks the patient to analyze, after which the indicated pain began, it almost always turns out that the attack arose after excessive (or moderate) consumption of fatty or spicy foods, alcohol or even stressful situations. Even some physical activities can lead to biliary colic, as a result of which the outflow of bile is disturbed.

The subsequent course of the disease

The disappearance of pain does not mean recovery. Gallstone disease is characterized by a chronic course, and therefore more accurately it should be called chronic calculous cholecystitis.

Acute cholecystitis

This is one of the most common complications of cholelithiasis. It occurs with high aggressiveness of microflora that has fallen into the gallbladder, where at this moment there is stagnation of bile.
Symptoms of acute cholecystitis are somewhat similar to biliary colic: pains of the same localization and intensity, also giving off to the right side of the body, nausea and repeated vomiting. However, there are also differences - the temperature, depending on the stage of the disease, rises from a slight fever (37-38 ° C) to very high numbers. The abdomen becomes sharply painful, with the transition of inflammation to the peritoneum, protective tension arises.
The main and most dangerous complication of acute cholecystitis is peritonitis, an inflammation of the peritoneum that dramatically aggravates the course of any disease of the abdomen and has high mortality rates.

Chronic calculous cholecystitis

The constant presence of stones in the gallbladder and stagnation of bile create favorable conditions for the existence of chronic inflammation. It is he who explains the fact that after colic, the patient's condition is rarely completely normalized. Usually at this time, the patient notes the presence of:

    pulling pains under the ribs on the right;
    their strengthening after eating fatty or fried foods, spices;
    bloating;
    diarrhea that occurs after a diet disorder;
    bitter taste in the mouth and heartburn.

If untreated, chronic calculous cholecystitis can lead to complications, such as:

    choledocholithiasis - the displacement of stones from the gallbladder into the common bile duct;
    cholangitis - the transition of inflammation from the bladder into the ducts (a rather serious complication);
    cicatricial strictures of the common bile duct - narrowing of its lumen due to scarring of the foci of inflammation in it;
    internal biliodigestive fistula - the formation of a through hole between the duct wall and the intestinal wall;
    dropsy of the gallbladder is a change in the organ that completely turns it off from digestion: the gallbladder is filled with mucous contents, bile does not penetrate into it.

Diagnostics

Diagnosis of cholelithiasis is quite simple and often does not require high-tech instrumental examination methods. When collecting an anamnesis, patients often note the appearance of a dull aching pain in the right hypochondrium with errors in the diet, as well as bitterness in the mouth.
Physical examination of a patient with gallstone disease in the "cold period", that is, without exacerbation, may be inconclusive. Only in acute cholecystitis or in the event of an attack of biliary colic, palpation in the right hypochondrium in the projection of the gallbladder can be painful.

    The main instrumental method for diagnosing cholelithiasis is abdominal ultrasound. This routine diagnostic method allows you to identify stones in the lumen of the gallbladder with an accuracy of 95%, as well as determine their size and quantity, assess the condition of the wall of the gallbladder, the diameter of the intrahepatic and extrahepatic bile ducts.

Multispiral computed tomography has limited capabilities in the diagnosis of cholelithiasis, since calculi are often X-ray negative and are not visible in this study.
In case of doubtful results of an ultrasound examination, as well as with a complicated course of cholelithiasis, the patient should perform magnetic resonance imaging. This method is the best method for diagnosing gallstone disease and its complications, as well as any other diseases of the hepatopancreatoduodenal organs.

How to treat cholelithiasis?

Depending on the degree of progression and severity, methods for treating gallstone disease are determined.
In the treatment of most diseases, doctors try to get along with conservative methods. Surgical intervention can lead to undesirable consequences for the functioning of the human body. If the disease takes a serious form, therapeutic treatment does not bring results, the doctor decides to treat the disease with surgery.

Treatment of cholelithiasis without surgery

At home, treatment of gallstone disease without surgery is used in the presence of cholesterol gallstones (X-ray negative) up to 15 mm in size with preserved contractile ability of the gallbladder and patency of the cystic duct.
Contraindications for drug dissolution of gallstones:

    acute inflammatory diseases of the gallbladder and biliary tract;
    stones with a diameter of more than 2 cm;
    liver disease, diabetes mellitus, gastric and duodenal ulcer, chronic pancreatitis;
    inflammatory diseases of the small and large intestines;
    obesity;
    pregnancy;
    “Disabled” - non-functioning gall bladder;
    pigment or carbonate stones;
    gall bladder cancer;
    multiple calculi, which occupy more than 50% of the volume of the gallbladder.

Ursodeoxycholic acid preparations are used, the action of which is aimed at dissolving only cholesterol stones, the drug is taken for 6 to 24 months. But the likelihood of relapse after dissolution of the stones is 50%. The dose of the drug, the duration of administration is established only by a doctor - therapist or gastroenterologist. Conservative treatment is possible only under the supervision of a physician.

    Shock wave cholelithotrepsy - treatment by crushing large calculi into small fragments using shock waves, followed by the administration of bile acid preparations (ursodeoxycholic acid). The probability of relapse is 30%.

Gallstone disease for a long time can be asymptomatic or asymptomatic, which creates certain difficulties in its detection in the early stages. This is the reason for the late diagnosis, at the stage of already formed gallstones, when the use of conservative methods of treatment is limited, and the only treatment remains surgical.

Surgery

Of the minimally invasive methods, laparoscopic cholecystectomy and laparoscopic cholecystolithotomy are used. These methods do not always allow you to achieve the desired result, therefore, a laparotomy cholecystectomy "from the neck" (abdominal gallbladder removal operation) is performed.
There are no clear indications for surgical treatment to date. Usually take into account the risk of activation of the disease and the occurrence of complications (10% for 5 years). The following factors may be grounds for surgical treatment:

    frequent development of symptoms of exacerbation of gallstone disease, accompanied by a severe clinical picture and violating the patient’s usual lifestyle;
    a history of previous complications of gallstone disease: acute cholecystitis, pancreatitis, gallstone fistula, etc .;
    calcified or “porcelain gallbladder” and adenomyomatosis of the gallbladder (due to oncological predisposition);
    the size of the stones is more than 2 cm and the presence of stone in the congenital abnormal gallbladder.

Additional reasons for surgical treatment may be diabetes mellitus, hemolytic anemia, enzymatic hyperbilirubinemia, which increase the likelihood of developing cholecystitis. There is an opinion on the advisability of conducting cholecystectomy (removal of the gallbladder) in patients under the age of 50 years with asymptomatic stones.
Contraindications to surgical treatment are coronary heart disease CHF III and IV f. C., myocardial infarction with Q wave and complications (rhythm disturbances, blockade, acute left ventricular failure), hypertension III tbsp. high and very high risk, heart failure III and IV f. class (NIIB – III art. According to the classification of ND Strazhesko and V.Kh. Vasilenko), acute cerebrovascular accident, severe obstructive pulmonary disease with respiratory failure of III art.

Stopping an attack of biliary colic

At the outpatient stage or before the transfer from the therapeutic department to the surgical relief of an attack of biliary colic is carried out according to the following scheme:

    bed rest;
    the use of painkillers (2–5 ml of a 50% analgin solution intramuscularly or 2–5 ml of a baralgin solution intramuscularly or intravenously, or a tram solution of 1-2 ml (50–100 mg) intramuscularly or intravenously; with severe pain, 1–2 ml is administered 2 % solution of promedol subcutaneously);
    antispasmodics (2-3 ml of a 2% solution of no-shpa or 2 ml of a 2% solution of papaverine intramuscularly);
    anticholinergics (1 ml of a 0.1% solution of atropine subcutaneously);
    cold to the right hypochondrium in the form of a bubble with cold water or ice;
    hunger.

Further treatment is carried out in the surgical department of the hospital, where most patients undergo surgical treatment.

Diet for exacerbation of the disease

Any exacerbation of the disease requires a certain diet. Only such an approach to treatment can minimize the frequency of possible attacks, relieve pain and improve the patient's condition.

    There is a list of popular diets for patients with cholelithiasis, common and effective from the list - diet No. 5.

What should be the food at home:

    Foods rich in monounsaturated fats, fatty acids help improve the emptying of bile. Such products are olive and rice oil, flaxseed.
    Maximum fiber intake helps minimize gallstones.
    Vegetables and fruits. Statistical observations show that people who eat a large amount of vegetables and fruits practically do not suffer from cholelithiasis.
    Nuts reduce the risk of diseases associated with the gallbladder and bile ducts.
    Sugar. A large consumption of sweets threatens the formation of calculi in the gall. Therefore, sweet tooth should monitor their diet and minimize the use of confectionery.
    Daily consumption of about 2 glasses of wine per day reduces the risk of gallstones.
    Coffee. Moderate consumption in no way affects the formation of stones in the gall, as a coffee drink stimulates the work of the gall and reduces cholesterol in bile.
    Drinking carbonated drinks is strictly prohibited. Unless you can sometimes indulge.
    Naturally, with gallstone disease and after its attacks, the use of fatty, spicy and fried foods is not recommended.

Nutrition must be balanced and proper. Give preference to steamed or boiled foods.

Prevention

If the patient has no symptoms of cholelithiasis and stones (stones) behave quite calmly, then it is not advisable to use the surgical treatment method. Such people need to take preventive measures that prevent the exacerbation of the disease.
Prevention of the disease includes: moderate balanced nutrition, normalization of weight, refusal from starvation and irregular food intake, adequate drinking regimen and moderate physical activity. It is advisable for people with cholelithiasis to walk every day, as it significantly improves the functioning of the gallbladder, and this prevents the stagnation of bile and the formation of new stones.