Gallstone disease (GSD) - symptoms, causes, diet and treatment of gallstone disease. Cholelithiasis. Symptoms Treatment. Diet Why cholelithiasis is more common in women

When an attack of gallstone disease occurs, it is accompanied by unpleasant symptoms: pain, fever, nausea and vomiting, and indigestion. To prevent exacerbation, it is important to know what the causes of such conditions are, what should be done before receiving first medical aid, and what are the methods of prevention.

Causes of an attack of cholelithiasis

Modern medicine understands gallstone disease (GSD) as a pathology accompanied by the formation of stones (calculi), which can accumulate in the gallbladder, as well as in the ducts. When the duct is completely blocked by a stone, an attack of cholelithiasis occurs. According to statistics, 20% of women and 10% of men suffer from cholelithiasis. At the same time, 60% of patients do not have attacks, although there are stones. In the absence of treatment, the likelihood of an attack increases by 2-3% with each passing year.

The causes of stone formation are inflammatory processes in the gallbladder, due to which the secreted digestive enzyme thickens and its viscosity increases. Natural outflow through the ducts becomes difficult. As a result, solid insoluble particles settle in the gallbladder: calcium salts, bile pigments, cholesterol. Gradually they become enveloped in mucus and particles of epithelium, acquiring at first, and over time, stones.

An attack of cholelithiasis occurs due to the traumatic movement of one or more gallstones. It can be provoked by an increase in liver activity and spasm.

List of common causes of cholelithiasis attack:

May occur. Carrying a fetus seriously affects the functioning of the liver and increases the load on it with each trimester. Squeezing of the bile ducts, which provokes cholecystitis, is caused by the growing placenta, which causes bile stagnation.

To understand what to do during an attack due to gallstones, it is important to determine the symptoms. Remember what preceded the illness. These are the questions the doctor will ask the patient.

Symptoms of an attack

The first thing a person feels on the eve of an attack is biliary colic. After eating, it occurs within 1-1.5 hours. This often happens at night, several hours after the person has fallen asleep. The main symptoms of an attack of gallstone disease:

1. Pain. Has a harsh character. It is felt on the right side of the abdomen with a shift towards the stomach. It becomes constant, sometimes radiating under the right shoulder blade or higher - into the shoulder and neck. Gradually, the pain syndrome grows and covers an increasingly larger area. The attack lasts from several minutes to hours. In its peak phase it can even cause painful shock.
2. Nausea. It is long lasting, but even when the stomach is emptied the patient does not feel relief. Intestinal motility slows down, and distinct bloating is observed.
3. Multiple autonomic disorders: increased sweating, tachycardia, sudden changes in pressure.
4. A slight increase in temperature (up to 38°C) suggests that the symptoms of an attack are provoked by stones in the gall bladder.

As the disease progresses, the condition worsens so much that it is no longer possible to lie quietly in bed. It is extremely difficult to find an acceptable body position to reduce pain. Breathing becomes difficult, and any movement of the chest only increases the torment. An attack occurs when a stone falls into the duodenum or after the administration of an antispasmodic.

If colic and other symptoms of an attack due to cholelithiasis do not stop within 6 hours, the doctor has reason to suspect an exacerbation of cholecystitis. A rise in temperature indirectly confirms the development of pancreatitis and cholangitis. The temperature can rise to 39°C, and a little later jaundice appears.

The most dangerous sign of a gallstone attack is a hard belly. This is how the body behaves when the gallbladder ruptures. Peritonitis sets in. The first thing to do when you have an attack due to gallstones is to call an ambulance. Without urgent surgery, death is inevitable.

How to relieve an attack of gallstone disease

The doctor is obliged to warn the patient that a single attack, even with timely medical care, will not be the only one. It is important for the patient to know what to do during an attack of gallstone disease, as well as after it.

In the future, the attacks will recur and the condition will worsen. Complex therapy is necessary, but the main thing is that the person himself must change his diet to reduce the load on the liver. In extreme cases, when the disease is advanced and the doctor cannot provide effective assistance using conservative methods, a decision is made to perform surgery (removal of the gallbladder).

First aid

If the patient experiences an attack of pain in the right abdomen, which only gets worse, as well as all the typical symptoms of cholelithiasis, take the following first aid measures:

1. Bed rest. You cannot get up until the attack stops.
2. Starvation. It is prohibited to eat until you have fully recovered from the attack.
3. When the temperature rises, cover with a blanket.
4. If the pain does not increase, but does not go away, an ice pack is placed on the stomach, and in no case a heating pad.
5. You need to drink water, especially if you feel nauseous. It should be warm.
6. Monitor the condition as the patient may lose consciousness. In this case, urgent hospitalization is necessary.

Drug therapy

On your own, before seeing a doctor or an ambulance, you can take a pill or give an injection of an antispasmodic: Drotaverine, Papaverine, Mebeverine in a minimal dosage. This will help relieve acute pain.

It is important to understand that these medications do not help the stone pass. If the stone remains in the duct and blocks it, the patient will only be helped in a clinical setting.

Help in hospital

Relieve pain with injections of Papaverine or Dibazol. No-Shpu or Eufillin is administered intramuscularly. Analgesics are used as auxiliary painkillers.

If these medications do not help, a potent drug is administered, for example, Tramal, Atropine, etc. If vomiting does not stop, use Cerucal. To replenish fluid losses, a drink based on a solution of Regidron or Citroglucosolan is prescribed.

Injections are a last resort treatment and are not used once the vomiting and pain stop. In this case, preference is given to tablet drugs. If swallowing is difficult, medications are administered by enema, for example, a combination of Analgin, Eufillion and belladonna.

If all the measures taken do not produce a tangible result, the doctor considers the need for surgery. Laparascopic cholecystectomy is indicated for stones larger than 1 cm in diameter. In this case, small punctures are made in the abdominal cavity and the organ is resected through them. , according to which it is executed. The patient's recovery rate and postoperative period can vary significantly depending on the technique. Further treatment of the disease after removal of the gallbladder is selected individually.

Proper nutrition

The main cause of an attack of the disease is an unbalanced diet, the presence of a large amount of fats and fried foods in the diet. After the attack is stopped, you can eat for the first time only after 12 hours. Let's say vegetable broth or compote without sugar. Only after a day can you return to a nutritious diet.

• pickled canned food, salted and pickled vegetables and fruits;
• sausages and smoked meats;
• pasta;
• baked goods;

fatty and fried;

• legumes;
• hot spices and herbs, as well as vegetables (onions, radishes, radishes, horseradish, etc.);
• alcohol.

The most useful foods after an attack of gallstone disease:

• cereal-based soups: rice, oatmeal, semolina;
• porridge, boiled or steamed in water;
• boiled vegetables and baked fruits;
• chicken and fish only boiled or steamed;
• crackers, stale bread;
• kefir, ayran, whey, matsoni, yogurt - without sugar.

After an attack, you can eat only fractionally; three meals a day are abandoned, switching to 5-6 meals a day with an interval of 2-3 hours. This regime must be followed for 3-4 months, after which slight relaxations can be allowed.

It is allowed to return to the usual eating schedule 8-9 months after the attack. It is recommended to completely avoid eating spicy food, as it provokes cramps.

Prevention of exacerbation of cholelithiasis

After a course of treatment in a hospital, rehabilitation therapy is prescribed. It includes various drugs that improve liver function, for example, Essentiale and other hepatoprotectors. It is important to prevent a possible attack in the future. A sedentary lifestyle, obesity, diabetes are risk factors.

You should stick to a strict diet for as long as possible; table No. 5 is recommended. It is necessary to refuse semi-finished and instant products. Food should be fresh and balanced towards increasing the proportion of protein and decreasing fat. Sweets are allowed only of natural origin: honey, dried fruits, berries. Physical exercise and quitting smoking, as well as avoiding stress (for example, changing occupations) greatly contribute to recovery.

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What to do? Should I agree to the operation or not? And how to live after it?

Gallstone disease (GSD), or cholelithiasis (from the Greek chole - bile and lithos - stone) is characterized by the formation of stones (calculi) in the gallbladder and ducts through which bile enters the intestines. lead to various forms of cholecystitis (inflammation of the walls of the gallbladder) - this often requires surgery, but sometimes you can do without it. The need to remove the gallbladder is determined by the attending physician.

The causes of gallstone formation are not fully understood. Only a few external and internal factors are known that increase the likelihood of cholelithiasis. According to the majority of both domestic and foreign statistical studies, women suffer from this disease 3-5 times more often than men, and according to some authors, even 8-15 (!) times.

The type of addition also plays a significant role. Thus, cholelithiasis and early symptoms are more common in women who are prone to obesity. Excess body weight is observed in approximately 2/3 of patients with cholelithiasis. Some congenital anomalies that impede the outflow of bile, for example, narrowing of the gallbladder duct, and acquired diseases (most often the result of chronic inflammation - hepatitis) also contribute to the development of the disease.

Of the external factors, the main role seems to be played by nutritional characteristics associated with geographic, national and economic characteristics. The increase in the prevalence of cholelithiasis, as well as its “rejuvenation” in economically developed countries, is explained by excessive consumption of foods rich in fat and animal proteins, which leads to increased salt deposition and stone formation. At the same time, in economically prosperous Japan, due to national nutritional characteristics, cholelithiasis is several times less common than in European countries, the USA or Russia.

Why do we need a gallbladder?

The gallbladder is a small sac (about 100 ml in volume) in which bile accumulates. When we eat, food goes to the stomach and then to the intestines. The intestine is divided into several sections, and the part of the intestine that immediately follows the stomach is called the duodenum. It is here that the digestion of fats that enter here with food begins. And bile takes a direct part in this process.

Bile is produced by the liver, and the liver works continuously. And bile is produced continuously. But bile is not needed all the time, but only when we eat. That's why nature created this small reservoir for bile - the gallbladder.

Through the bile duct system, bile produced by the liver enters the gallbladder, where it remains until we start eating. Then the walls of the bladder contract and push out bile. And it is sent through the bile ducts to the duodenum, where it enters into the process of digesting food.

The gallbladder itself does not produce any digestive enzymes; it simply stores bile until it is needed. Therefore, it is not a vital organ. Of course, our body needs it, but we can live without it. In simple terms, living without this organ is not as “comfortable” as living with it. But our body adapts quite well to this loss and in most cases, after a year or a year and a half, it no longer “notices” its absence. Especially if you follow the basic rules of a healthy diet: eat often, but in small portions, do not abuse alcohol, spicy, fatty foods. But this does not mean at all that you need to constantly deny yourself everything. It’s just that the body, especially in the first time after removal of the gallbladder, needs support.

So there is no need to be afraid that the quality of your life will change significantly after the removal of this organ. If the bladder is completely or almost completely filled with stones, if its wall is changed to such an extent that it is unable to contract, then it still does not fulfill its function. And its useless presence only leads to troubles: hepatic colic, inflammation (even purulent), etc.

Gallstone disease, symptoms

Gallstones can manifest themselves in different ways. Sometimes there is aching pain in the right hypochondrium, which extends to the back area (right shoulder blade). Pain occurs or intensifies after eating fatty foods, and is mostly paroxysmal in nature. There are usually no severe pain attacks. Weakness, malaise, irritability, belching, and unstable stools are often observed.

Sometimes cholelithiasis manifests itself as a sudden severe pain attack. Provoking factors are the consumption of fatty or spicy foods, negative emotions, severe physical stress, prolonged forced stay in an uncomfortable position (for example, when weeding beds and other agricultural work). Such pains often occur at night, are located in the right hypochondrium and epigastric region, spread to the entire upper half of the abdomen and radiate to the right shoulder blade, right shoulder, and neck. The intensity of the pain can be so great that patients groan, rush about in bed, and cannot find a position that alleviates their condition. Often the attack is accompanied by indomitable nausea. In some cases, cholelithiasis is manifested by pain of varying intensity in the heart area (in the absence of pain in the right hypochondrium). If you suspect cholelithiasis, you should consult a doctor.

Surgery for cholelithiasis

In case of cholelithiasis, symptoms of the disease, especially with frequent exacerbations (colic), chronic inflammation (cholecystitis), surgery to remove the gallbladder, or cholecystectomy, is often indicated. In this case, the gallbladder, as the source of all troubles, is removed.

There are two types of this operation:

• Open cholecystectomy.
• Laparoscopic cholecystectomy.

In both cases, the gallbladder is removed. The only difference is how the surgeon “gets” to the gallbladder.

In the first case, an incision is made in the anterior abdominal wall and the gallbladder is “taken out” through it and removed.

In the second, 4 small incisions are made (about 1 cm), through which special instruments are inserted that allow you to see what is in the abdominal cavity (special optics) and remove the gallbladder.

The first method is older, the second began to be used not so long ago.

The laparoscopic method is more gentle and less traumatic. After such an operation, the patient remains in the clinic for 3–4 days. Full recovery occurs much faster than after open cholecystectomy - after 7 days. And the scar after such an operation is almost invisible.

But there are conditions when laparoscopic surgery is impossible and then the only method of choice is open cholecystectomy.

Here is their list:

In each specific case, the decision remains with the attending physician, who takes into account the general condition of the patient, the presence of concomitant chronic diseases and other factors.

When there is no need for surgery: crushing gallstones

Dissolution of stones or crushing of stones (lithotripsy) is indicated for small stones (up to 1 cm) and single stones. The crushing of gallstones is carried out using ultrasound or electromagnetic waves. Crushing of stones in the gall bladder occurs due to the impact of a shock wave on the stone. At the focusing point, the wave energy reaches its maximum. In this case, deformation occurs in the stone, which exceeds the strength of the stone. The stone receives not just one shock wave, but many - from 1500 to 3500 (depending on the composition of the stone). These multiple shock waves, focused on the stone, destroy it into small particles, the size of which does not exceed the diameter of the gallbladder duct, which allows them to be excreted through this duct. Then they enter the intestines and are removed from the body. Larger fragments that cannot pass through the duct remain in the gallbladder. Therefore, to increase the effectiveness of treatment, it is advisable to add bile acid preparations (course administration). The main disadvantage of this method is the high probability of relapse, that is, the reappearance of gallstones. After 5 years, the relapse rate is 50%.

Dissolving gallstones with the help of medications is possible, but only if they are of a cholesterol nature. For this purpose, ursodeoxycholic acid is used at a dose of 10 mg/kg per day in 2-3 doses. The course of treatment lasts 6–12 months. To prevent the re-formation of stones, it is recommended to take the drug for several more months after their dissolution.

Of course, in all variants of the course of cholelithiasis, regardless of the chosen treatment method, it is recommended to adhere to nutritional rules that are gentle on the gastrointestinal tract. You should eat foods containing a large amount of plant fiber, a reduced amount of proteins and fats. Food should be taken in small portions 5-6 times a day.

A combination of medications, a healthy lifestyle and, if necessary, surgical treatment will relieve you of inflammation and attacks of pain.

Why is it necessary to follow a diet after gallbladder removal?

Many people who have had their gallbladder removed do not understand why they need a diet, because the gallbladder is no longer there! And there are no stones either... Why do you need to eat differently?

Let me explain: you have had the consequence removed - the stones and the bubble in which they are formed, and the disease - metabolic disorder - has not gone away, you continue to live with her. Now stones can form in the bile ducts, which is much more dangerous. And proper balanced nutrition, which we usually call a diet, will gradually normalize metabolism and you will get rid of cholelithiasis forever.

Moreover, if in the presence of a gallbladder, the bile in it became concentrated, which gave it the opportunity to exhibit disinfectant properties and kill pathogenic microbes, now it enters directly into the duodenum- constantly, having no place to accumulate. This bile cannot help digest large amounts of food, since there is no reservoir where it accumulated - the bladder has been removed.

It is for this reason that it is recommended fractional meals 5-6 times throughout the day and give up irrational consumption of fatty foods. Yes, fat is needed, but in small quantities. You also need to drink a lot of water - at least 1.5 liters, which will dilute the bile. And adhere to the list of permitted and prohibited foods for cholelithiasis (you remember - the disease has not gone away!), which is given above.

I hope that the article was useful for you and helped you understand such a complex phenomenon as cholelithiasis, its symptoms and causes, surgical treatment and nutrition for the formation of gallstones.

Be healthy! We eat rationally and correctly!

is a pathological process in which the gallbladder and ducts form stones (stones ). Due to the formation of gallstones, the patient develops gallstones.

In order to understand the nature of gallstone disease, it is necessary, first of all, to understand how formation and transportation occur . Human liver cells produce from 500 ml to 1 liter of bile every day. Bile is required for food processing, especially .

Bile from the liver (from the bile capillaries) first ends up in the hepatic ducts, after which it enters the duodenum through the common hepatic bile duct. The process of passage of bile into the duodenum from this duct occurs with the help of a muscle called “ sphincter of Oddi " If the duodenum is empty, the sphincter closes and bile flows. In this case, stretching of the gallbladder may occur. There may be an accumulation of bile in it, which can be stored there for a long time.

Features of gallstones

Gallstones (stones ) are the main manifestation of gallstone disease. These formations consist of bile components: the stone contains , calcium , . The size of the stones can vary: they can be the size of grains of sand, or they can be large formations, several centimeters in diameter. A stone grows over a certain time: for example, from the size of a grain of sand, a stone can grow up to 1 cm in six months. Stones have different shapes: there are oval, round stones, polyhedron-shaped formations, etc. The strength of stones also varies: there are both very strong stones and and fragile, crumbling when touched. Cracks and thorns are sometimes observed on the surface of stones, but it can also be smooth. The most common stones are in the gall bladder. This condition is usually called cholelithiasis or calculosis gallbladder. In more rare cases, a person develops choledocholithiasis , that is, stones appear in the bile ducts of the liver. Stones form in the bile ducts either one at a time or several dozen at a time. Sometimes their number is in the hundreds. But even one stone can provoke a serious complication of the disease. In this case, small stones are considered more dangerous.

Causes of gallstone disease

Today there is no single accurate theory that would explain the cause and process of the appearance of gallstones. The most likely causes of this disease are considered to be disturbances in the body's metabolic processes, inflammation that occurs in the area of ​​the gallbladder wall, congestion in the bile ducts, as well as other phenomena. As a rule, the main reasons why a person develops symptoms of gallstone disease are an unhealthy lifestyle in general and poor nutrition in particular. Other factors are also important: insufficient activity, overeating or irregular eating, sedentary work can provoke the development of gallstone disease. In women, the disease occurs more often than in men, and women who have had several births are most susceptible to cholelithiasis.

Symptoms of gallstone disease

Due to the likelihood of stagnation in the gallbladder, this is where stones form most often. In some cases, symptoms of gallstone disease do not appear for a long period of time after the stones have formed. Stones sometimes do not affect the function of the gallbladder, so a person may not even suspect that he has stones.

However, very often stones that appear in the gallbladder provoke spasms or cause expansion of the gallbladder. In this case, the symptoms of cholelithiasis are manifested by painful attacks. The pain, which is localized under the right costal arch, can be short-lived or long-lasting, with pain varying in intensity. If the inflammatory process in the wall of the gallbladder does not manifest itself, then the pain may disappear without any consequences. In this case, such phenomena are usually called hepatic or biliary. colic .

With cholelithiasis, pain sometimes radiates to the area of ​​the shoulder blades, especially under the right shoulder blade. Sometimes the pain radiates to the heart area. At the same time, it sometimes appears : The rhythm of heart contractions is disrupted. Pain often appears after a person has eaten something spicy or fatty. To digest such foods, bile is needed, therefore, contractions of the gallbladder occur. Sometimes vomiting may occur.

If there is acute inflammation of the gallbladder, the pain may continue without subsiding for several days or even weeks. The temperature sometimes rises a little. It is important to consider that some subsidence of pain is not always a sign that inflammation is subsiding. We can talk about the cessation of the inflammatory process only when the pain is completely absent for several days, and at the same time the person’s body temperature normalizes.

If there is chronic inflammation, then pain in the right hypochondrium appears periodically, it can be both severe and aching. The person also feels discomfort in this area.

When developing as a consequence of the disease, the symptoms of cholelithiasis are complemented by the manifestation of severe pain in the upper half of the abdomen, near the navel. Sometimes the pain may radiate to the lower back, and the patient also experiences frequent vomiting.

Diagnosis of cholelithiasis

The main research method in the process of diagnosing cholelithiasis is ultrasonography abdominal cavity. The patient is also prescribed cholangiography , cholecystography . The ultrasound method has significantly improved the accuracy of diagnosis. It is very important that this study is carried out by a specialist who has experience in identifying such diseases and their characteristics. So, it happens that the contents of the intestine and other anatomical structures are mistaken for stones. There is a possibility that stones will not be detected during the examination; it is especially difficult to determine their presence in the bile ducts.

Treatment of cholelithiasis

Today, treatment of gallstone disease often consists of cholecystectomy , that is, removal of the gallbladder in which stones are found. Removal of the gallbladder does not have a decisive effect on human life.

If the stones are freely located in the cavity of the gallbladder and they consist exclusively of cholesterol, and their size does not exceed 2 cm, then sometimes the stones are dissolved. This procedure is performed using chenodeoxycholic And ursodeoxycholic acids It is important to take into account that in this case the treatment lasts at least a year, and very often after some time the fireplaces re-form in patients. However, the method can be quite effective. Stones are also destroyed using the power of a special wave created by special generators. In this case, it is important that the stones contain only cholesterol, their number does not exceed three, and their size is no more than two centimeters. There are also a number of contraindications for this method of treatment: inflammation of the gallbladder, pancreas, liver, , abdominal vessels, etc.

Today, cholelithiasis is also treated using a method called laparoscopic cholecystectomy. Such surgical intervention is less traumatic and is performed by punctures of the abdominal wall and insertion of microsurgical instruments through the punctures. This method also has some disadvantages. First of all, the gallbladder cannot be removed this way in every case. If the structure of this zone is atypical, traditional cholecystectomy should be used. Also, this method of treatment cannot be used in the presence of adhesions and severe inflammation in the gallbladder.

The doctors

Medicines

Prevention of gallstone disease

As a preventive measure for cholelithiasis, it is important to eliminate all risk factors for its occurrence. You should try to lead a healthy lifestyle, adhere to the principles of proper nutrition, and avoid obesity. If a person has already been diagnosed with gallstone disease, then he should constantly undergo examinations and consultations with a specialist.

Diet, nutrition for gallstone disease

In order to prevent further formation of stones during cholelithiasis, the patient should adhere to the principles of a rational, healthy diet, and also follow a specially designed for patients with this disease. The main feature of dietary nutrition, which should be used in the treatment of cholelithiasis, is to ensure proper cholesterol metabolism . To do this, it is important to reduce the calorie content of food by removing a certain amount of fats and carbohydrates from your daily diet, and also stop eating foods that contain a lot of cholesterol. First of all, the latter concerns liver, egg yolk, fatty fish and meats, lard and a number of other products. The diet for gallstone disease should not include dishes from these products.

Helps remove excess cholesterol from the body magnesium salts . Therefore, the diet should contain those foods that have a high content of magnesium salts. The diet for gallstone disease should include apricots, oatmeal and buckwheat.

Cholesterol in bile must be contained in dissolved form. To do this, you should increase the level of alkali in the bile. In this case, it is important to include in the diet products of plant origin, alkaline mineral waters, dishes and foods with high content (it is found in butter and other dairy products). In addition, the diet for gallstone disease includes many vegetable dishes. It is important to note that all dishes must be steamed, baked, or boiled. You should eat six times a day, and the portions should not be too large.

You should salt your food in moderation; you should limit rich baked goods.

Experts included sausages, smoked products, sauces, fried foods, animal fats, legumes, spices and spices, cream cakes and pastries, coffee, cocoa, and chocolate among the products prohibited for patients with cholelithiasis. Patients should follow such a diet for several years.

Complications of gallstone disease

The appearance of stones is fraught not only with disruption of organ functions, but also with the occurrence of inflammatory changes in the gallbladder and nearby organs. So, because of the stones, the walls of the bladder can be injured, which, in turn, provokes inflammation. If the stones pass through the cystic duct with bile from the gallbladder, the flow of bile may be obstructed. In the most severe cases, stones can block the entrance and exit of the gallbladder, becoming lodged in it. With such phenomena, stagnation of bile occurs, and this is a prerequisite for the development of inflammation. The inflammatory process can develop over several hours and over several days. Under such conditions, the patient may develop an acute inflammatory process of the gallbladder. In this case, both the degree of damage and the rate of development of inflammation can be different. Thus, both slight swelling of the wall and its destruction and, as a consequence, rupture of the gallbladder are possible. Such complications of cholelithiasis are life-threatening. If inflammation spreads to the abdominal organs and peritoneum, then the patient develops peritonitis . As a result, multiple organ failure may become a complication of these phenomena. In this case, disruption of the functioning of blood vessels, kidneys, heart, and brain occurs. With severe inflammation and high toxicity of microbes multiplying in the affected wall of the gallbladder, infectious-toxic shock can appear immediately. In this case, even resuscitation measures do not guarantee that the patient will be able to be brought out of this state and death will be avoided.

List of sources

• Gallstone disease / S. A. Dadvani [et al.]. - M.: Vidar-M Publishing House, 2000.
• Grigorieva I. N., Nikitin Yu. P. Lipid metabolism and cholelithiasis. - Novosibirsk, 2005.
• Ilchenko A. A. Gallstone disease. - M., 2004.
• Guide to Gastroenterology / ed. F.I. Komarov, A.L. Grebenev. - M.: Medicine, 1995. - T.2.

Gallstone disease (GSD) is a disease characterized by the formation of stones in the gallbladder (cholecystolithiasis) and the common bile duct (choledocholithiasis), which can occur with symptoms of biliary (biliary, hepatic) colic in response to transient stone obstruction of the cystic or common bile duct, accompanied by spasm of smooth muscles and intraductal hypertension.

Between the ages of 21 and 30, cholelithiasis affects 3.8% of the population, from 41 to 50 years – 5.25%, over 60 years – up to 20%, over 70 years – up to 30%. The predominant gender is female (3–5:1), although there is a tendency for the incidence to increase in men.

Factors predisposing to the formation of gallstones (primarily cholesterol): female gender; age (the older the patient, the higher the likelihood of cholelithiasis); genetic and ethnic characteristics; nature of nutrition - excessive consumption of fatty foods high in cholesterol, animal fats, sugar, sweets; pregnancy (history of multiple births); obesity; starvation; geographical areas of residence; diseases of the ileum - short colon syndrome, Crohn's disease, etc.; the use of certain medications - estrogens, octreotide, etc.

Classification

1. By the nature of the stones

1.1 Composition: cholesterol; pigmented; mixed.

1.2 By localization: in the gallbladder; in the common bile duct (choledocholithiasis); in the hepatic ducts.

1.3 By number of stones: single; multiple.

2. According to the clinical course

2.1 latent flow;

2.2 with the presence of clinical symptoms: painful form with typical biliary colic; dyspeptic form; under the guise of other diseases.

3. Complications: acute cholecystitis; hydrocele of the gallbladder; choledocholithiasis; obstructive jaundice; acute pancreatitis; purulent cholangitis; biliary fistulas; stricture of the major duodenal papilla.

Clinical picture

Often cholelithiasis is asymptomatic (latent course, characteristic of 75% of patients), and stones are discovered accidentally during an ultrasound. The diagnosis of cholelithiasis is made based on clinical data and ultrasound results. The most common variant is biliary colic: observed in 60–80% of people with gallstones and 10–20% of people with stones in the common bile duct.

The main clinical manifestation of cholelithiasis is biliary colic. It is characterized by acute visceral pain localized in the epigastric or right hypochondrium; less often, pain occurs only in the left hypochondrium, precordial region or lower half of the abdomen, which significantly complicates diagnosis. In 50% of patients, pain radiates to the back and right scapula, interscapular area, right shoulder, and less often to the left half of the body. The duration of biliary colic ranges from 15 minutes to 5–6 hours. Pain lasting more than 5–6 hours should alert the doctor to complications, especially acute cholecystitis. The pain syndrome is characterized by increased sweating, a grimace of pain on the face and restless behavior of the patient. Sometimes nausea and vomiting occur. The onset of pain may be preceded by the consumption of fatty, hot, spicy foods, alcohol, physical activity, and emotional experiences. Pain is associated with overstretching of the gallbladder wall due to increased intravesical pressure and spastic contraction of the sphincter of Oddi or cystic duct. With biliary colic, the body temperature is usually normal, the presence of hyperthermia in combination with symptoms of intoxication (tachycardia, dry and coated tongue), as a rule, indicates the addition of acute cholecystitis.

The presence of jaundice is considered a sign of biliary obstruction.

When collecting anamnesis, it is necessary to especially carefully question the patient regarding episodes of abdominal pain in the past, since as cholelithiasis progresses, episodes of biliary colic recur, become protracted, and the intensity of pain increases.

Nonspecific symptoms are also possible, for example, heaviness in the right hypochondrium, manifestations of biliary dyskinesia, flatulence, and dyspeptic disorders.

An objective examination may reveal symptoms of chronic cholecystitis (vesical symptoms). I'M WITH. Zimmerman (1992) systematized the physical symptoms of chronic cholecystitis into three groups as follows.

Symptoms of the first group (segmental reflex symptoms) are caused by prolonged irritation of the segmental formations of the autonomic nervous system innervating the biliary system, and are divided into two subgroups:

1. Viscero-cutaneous reflex pain points and zones– characterized by the fact that finger pressure on organ-specific points of the skin causes pain:

Painful McKenzie point located at the intersection of the outer edge of the right rectus abdominis muscle with the right costal arch;

Painful Boas point– localized on the posterior surface of the chest along the paravertebral line on the right at the level of the X-XI thoracic vertebrae;

Zakharyin-Ged zones of cutaneous hypertension– extensive areas of severe pain and hypersensitivity, spreading in all directions from the Mackenzie and Boas points.

2. Cutaneous-visceral reflex symptoms– are characterized by the fact that impact on certain points or zones causes pain going deeper towards the gallbladder:

Aliyev's symptom– pressure on the Mackenzie or Boas points causes not only local pain directly under the palpating finger, but also pain going deeper towards the gallbladder;

Eisenberg's sign-I– with a short blow or tapping with the edge of the palm below the angle of the right shoulder blade, the patient, along with local pain, feels a pronounced irradiation deep into the area of ​​the gallbladder.

The symptoms of the first group are natural and characteristic of exacerbation of chronic cholecystitis. The symptoms of Mackenzie, Boas, and Aliev are considered the most pathognomonic.

Symptoms of the second group are caused by the spread of irritation of the autonomic nervous system beyond the segmental innervation of the biliary system to the entire right half of the body and right limbs. In this case, a right-sided reactive autonomic syndrome is formed, characterized by the appearance of pain upon palpation of the following points:

Bergmann orbital point(at the upper inner edge of the orbit);

Jonash's occipital point;

Mussi-Georgievsky point(between the legs of the right m. sternocleidomastoideus)

– right-sided phrenicus symptom;

Kharitonov's interscapular point(at the middle of a horizontal line drawn through the middle of the inner edge of the right shoulder blade);

Lapinski's femoral point(middle of the inner edge of the right thigh);

point of the right popliteal fossa;

plantar point(on the back of the right foot).

Pressure on the indicated points is produced by the tip of the pointer

body finger. Symptoms of the second group are observed in the often recurrent course of chronic cholecystitis. The presence of pain at several points simultaneously, or even more so at all points, reflects the severity of the disease.

Symptoms of the third group are detected by direct or indirect (by tapping) irritation of the gallbladder (irritative symptoms). These include:

Murphy's sign– While the patient is exhaling, the doctor carefully immerses the tips of the four half-bent fingers of his right hand under the right costal arch in the area where the gallbladder is located, then the patient takes a deep breath, the symptom is considered positive if during exhalation the patient suddenly interrupts it due to the appearance of pain when the fingertips touch with a sensitive, inflamed gallbladder. At the same time, a grimace of pain may appear on the patient’s face;

Ker's sign– pain in the right hypochondrium near the gallbladder with deep palpation;

Hausmann's sign– the appearance of pain with a short blow with the edge of the palm below the right costal arch at the height of inspiration);

Lepene-Vasilenko symptom– the occurrence of pain when delivering jerky blows with the fingertips while inhaling below the right costal arch;

Ortner-Grekov symptom– the appearance of pain when tapping the right costal arch with the edge of the palm (pain appears due to shaking of the inflamed gallbladder);

Eisenberg-II sign– in a standing position, the patient rises on his toes and then quickly falls on his heels; with a positive symptom, pain appears in the right hypochondrium due to shaking of the inflamed gallbladder.

The symptoms of the third group are of great diagnostic importance, especially in the remission phase, especially since in this phase the symptoms of the first two groups are usually absent.

Symptoms of involvement of the solar plexus in the pathological process

With a long course of chronic cholecystitis, the solar plexus may be involved in the pathological process - secondary solar syndrome.

The main signs of solar syndrome are:

Pain in the navel area radiating to the back (solaralgia), sometimes the pain is burning in nature;

Dyspeptic symptoms (they are difficult to distinguish from the symptoms of dyspepsia due to exacerbation of chronic cholecystitis itself and concomitant pathology of the stomach);

Palpation identification of pain points located between the navel and the xiphoid process;

Pekarsky's symptom is pain when pressing on the xiphoid process.

Diagnostics

For the uncomplicated course of cholelithiasis, changes in laboratory parameters are uncharacteristic. With the development of acute cholecystitis and concomitant cholangitis, leukocytosis may appear, an increase in ESR, an increase in the activity of serum aminotransferases, cholestasis enzymes (alkaline phosphatase, gamma-glutamyl transpeptidase), and bilirubin levels.

If there is a clinically justified suspicion of cholelithiasis, an ultrasound scan is first necessary. The diagnosis of cholelithiasis is confirmed using CT, magnetic resonance cholangiopancreatography, cholecystography, endoscopic cholecystopancreaticography.

Mandatory instrumental studies

■ Ultrasound of the abdominal organs as the most accessible method with high sensitivity and specificity for identifying gallstones. For stones in the gall bladder and cystic duct, ultrasound sensitivity is 89%, specificity is 97%; for stones in the common bile duct, sensitivity is less than 50%, specificity is 95%. A targeted search is required: dilation of intra- and extrahepatic bile ducts; stones in the lumen of the gallbladder and bile ducts; signs of acute cholecystitis in the form of thickening of the gallbladder wall more than 4 mm, identification of a “double contour” of the gallbladder wall.

■ Plain radiography of the gallbladder area: the sensitivity of the method for detecting stones is less than 20% due to their frequent X-ray negativity.

■ Endoscopy: carried out to assess the condition of the stomach and duodenum, to examine the major papilla of the duodenum if choledocholithiasis is suspected.

Additional instrumental studies

■ Oral or intravenous cholecystography. A significant result of the study can be considered a “disconnected” gallbladder (extrahepatic bile ducts are contrasted, but the bladder is not detected), which indicates obliteration or blockage of the cystic duct.

■ CT scan of the abdominal organs (gallbladder, bile ducts, liver, pancreas) with quantitative determination of the Hansfeld attenuation coefficient of gallstones; The method makes it possible to indirectly judge the composition of stones by their density.

■ Endoscopic cholecystopancreaticography: a highly informative method for studying the extrahepatic ducts if a common bile duct stone is suspected or to exclude other diseases and causes of obstructive jaundice.

■ Dynamic cholescintigraphy allows you to assess the patency of the bile ducts in cases where endoscopic cholecystopancreaticography is difficult. In patients with cholelithiasis, a decrease in the rate of entry of the radiopharmaceutical into the gallbladder and intestines is determined.

Differential diagnosis

Pain syndrome in cholelithiasis should be differentiated from the following conditions.

■ Biliary sludge: sometimes a typical clinical picture of biliary colic is observed. Ultrasound reveals the presence of bile sediment in the gallbladder.

■ Functional diseases of the gallbladder and biliary tract: no stones are found during examination. Signs of impaired contractility of the gallbladder (hypo- or hyperkinesia), spasm of the sphincter apparatus (dysfunction of the sphincter of Oddi) are detected.

■ Pathology of the esophagus: esophagitis, esophagospasm, hiatal hernia. Characterized by pain in the epigastric region and behind the sternum in combination with typical changes during endoscopy or x-ray examination of the upper gastrointestinal tract.

■ Peptic ulcer of the stomach and duodenum: characterized by pain in the epigastric region, sometimes radiating to the back and decreasing after eating, taking antacids and antisecretory drugs. An endoscopy is required.

■ Diseases of the pancreas: acute and chronic pancreatitis, pseudocysts, tumors. Typical pain is in the epigastric region, radiating to the back, provoked by food intake and often accompanied by vomiting. The diagnosis is supported by increased activity of amylase and lipase in the blood serum, as well as typical changes in the results of radiological diagnostic methods. It should be taken into account that cholelithiasis and biliary sludge can lead to the development of acute pancreatitis.

■ Liver diseases: characterized by dull pain in the right hypochondrium, radiating to the back and right shoulder blade. The pain is usually constant (which is not typical for pain syndrome with biliary colic), associated with liver enlargement, and liver tenderness on palpation is characteristic.

■ Diseases of the colon: irritable bowel syndrome, tumors, inflammatory lesions (especially when the hepatic flexure of the colon is involved in the pathological process). Pain syndrome is often caused by motor disorders. The pain is often relieved by bowel movements or passing gas. For differential diagnosis of functional and organic changes, colonoscopy or irrigoscopy is recommended.

■ Diseases of the lungs and pleura: an X-ray examination of the chest organs is necessary.

■ Skeletal muscle pathology: pain in the right upper quadrant of the abdomen associated with movements or taking a certain body position. Palpation of the ribs may be painful; Increased pain is possible with tension in the muscles of the anterior abdominal wall.

Treatment

Goals of therapy: removal of gallstones (either the stones themselves from the biliary tract, or the gallbladder along with the stones); relief of clinical symptoms without surgical intervention (if there are contraindications to surgical treatment); preventing the development of complications, both immediate (acute cholecystitis, acute pancreatitis, acute cholangitis) and long-term (gallbladder cancer).

Indications for hospitalization in a surgical hospital: recurrent biliary colic; acute and chronic cholecystitis and their complications; obstructive jaundice; purulent cholangitis; acute biliary pancreatitis.

Indications for hospitalization in a gastroenterological or therapeutic hospital: chronic calculous cholecystitis - for a detailed examination and preparation for surgical or conservative treatment; exacerbation of cholelithiasis and the condition after cholecystectomy (chronic biliary pancreatitis, dysfunction of the sphincter of Oddi).

Duration of inpatient treatment: chronic calculous cholecystitis – 8–10 days, chronic biliary pancreatitis (depending on the severity of the disease) – 21–28 days.

Treatment includes diet therapy, the use of medications, external lithotripsy methods and surgery.

Diet therapy: at all stages, 4–6 meals a day are recommended with the exclusion of foods that increase the secretion of bile, the secretion of the stomach and pancreas. Avoid smoked meats, refractory fats, and irritating seasonings. The diet should include a large amount of plant fiber with the addition of bran, which not only normalizes intestinal motility, but also reduces the lithogenicity of bile. With biliary colic, fasting is necessary for 2-3 days.

Oral litholytic therapy is the only effective conservative method for the treatment of cholelithiasis. To dissolve stones, bile acid preparations are used: ursodeoxycholic and chenodeoxycholic acids. Treatment with bile acid preparations is carried out and monitored on an outpatient basis.

The most favorable conditions for the outcome of oral lithotripsy are: early stages of the disease; uncomplicated course of cholelithiasis, rare episodes of biliary colic, moderate pain syndrome; in the presence of pure cholesterol stones (“float up” during oral cholecystography); in the presence of non-calcified stones (CT attenuation coefficient less than 70 Hansfeld units); with stone sizes no more than 15 mm (in combination with shock wave lithotripsy - up to 30 mm), the best results are observed with stone diameters up to 5 mm; with single stones occupying no more than 1/3 of the gallbladder; with preserved contractile function of the gallbladder.

Daily doses of drugs are determined taking into account the patient’s body weight. The dose of chenodeoxycholic acid (as monotherapy) is 15 mg/(kg day), ursodeoxycholic acid (as monotherapy) – 10–15 mg/(kg day). Preference should be given to ursodeoxycholic acid derivatives, as they are more effective and have fewer side effects. The most effective is considered to be a combination of ursodeoxycholic and chenodeoxycholic acids at a dose of 7–8 mg/(kg·day) of each drug. The drugs are prescribed once at night.

Treatment is carried out under ultrasound control (once every 3–6 months). If there are positive dynamics on ultrasound 3–6 months after the start of therapy, it is continued until the stones are completely dissolved. The duration of treatment usually varies from 12 to 24 months with continuous use of drugs. Regardless of the effectiveness of litholytic therapy, it reduces the severity of pain and reduces the likelihood of developing acute cholecystitis.

The effectiveness of conservative treatment is quite high: with proper selection of patients, complete dissolution of stones is observed after 18–24 months in 60–70% of patients, but relapses of the disease are common.

The absence of positive dynamics according to ultrasound data after 6 months of taking the drugs indicates the ineffectiveness of oral litholytic therapy and indicates the need to discontinue it.

Since the pain syndrome in biliary colic is associated to a greater extent with spasm of the sphincter apparatus, the prescription of antispasmodics (mebeverine, pinaverium bromide) in standard daily doses for 2–4 weeks is justified.

Antibacterial therapy is indicated for acute cholecystitis and cholangitis.

Methods of surgical treatment: cholecystectomy - laparoscopic or open, extracorporeal shock wave lithotripsy.

Indications for surgical treatment for cholecystolithiasis: the presence of large and small stones in the gallbladder, occupying more than 1/3 of its volume; course of the disease with frequent attacks of biliary colic, regardless of the size of the stones; disabled (non-functioning) gallbladder; GSD complicated by cholecystitis and/or cholangitis; combination with choledocholithiasis; Cholelithiasis complicated by the development of Mirizzi syndrome; Cholelithiasis complicated by dropsy, empyema of the gallbladder; GSD complicated by perforation, penetration, fistulas; Cholelithiasis complicated by biliary pancreatitis; Cholelithiasis, accompanied by obstruction of the common bile duct and obstructive jaundice.

In asymptomatic cases of cholelithiasis, as well as in a single episode of biliary colic and infrequent pain attacks, a wait-and-see approach is most justified. If indicated, lithotripsy may be performed in these cases. It is not indicated for asymptomatic stone carriers, since the risk of surgery outweighs the risk of developing symptoms or complications.

In some cases, and only according to strict indications, it is possible to perform laparoscopic cholecystectomy in the presence of asymptomatic stone carriers to prevent the development of clinical manifestations of cholelithiasis or gallbladder cancer. Indications for cholecystectomy for asymptomatic stone carriers: calcified (“porcelain”) gallbladder; stones larger than 3 cm; upcoming long stay in the region with a lack of qualified medical care; sickle cell anemia; upcoming organ transplantation to the patient.

Laparoscopic cholecystectomy is characterized by less trauma, a shorter postoperative period, shorter hospital stay, and better cosmetic results. In any case, one should keep in mind the possibility of converting the operation to an open one if attempts to remove the stone using the endoscopic method are unsuccessful. There are practically no absolute contraindications to laparoscopic procedures. Relative contraindications include acute cholecystitis with a disease duration of more than 48 hours, peritonitis, acute cholangitis, obstructive jaundice, internal and external biliary fistulas, liver cirrhosis, coagulopathy, unresolved acute pancreatitis, pregnancy, morbid obesity, severe cardiopulmonary failure.

Shock wave lithotripsy is used very limitedly, as it has a fairly narrow range of indications and a number of contraindications and complications. Extracorporeal shock wave lithotripsy is used in the following cases: the presence of no more than three stones in the gallbladder with a total diameter of less than 30 mm; the presence of stones that “pop up” during oral cholecystography (a characteristic sign of cholesterol stones); a functioning gallbladder, according to oral cholecystography; reduction of the gallbladder by 50%, according to scintigraphy.

It should be borne in mind that without additional treatment with ursodeoxycholic acid, the recurrence rate of stone formation reaches 50%. In addition, the method does not prevent the possibility of developing gallbladder cancer in the future.

Endoscopic papillosphincterotomy is indicated primarily for choledocholithiasis.

All patients with cholelithiasis are subject to dispensary observation in an outpatient setting. It is especially necessary to carefully monitor patients with asymptomatic stone-carrying stones, give a clinical assessment of the anamnesis and physical signs. If any dynamics appear, a laboratory examination and ultrasound are performed. Similar measures are carried out if there is a single episode of biliary colic in the anamnesis.

When carrying out oral litholytic therapy, regular monitoring of the condition of stones using ultrasound is necessary. In the case of therapy with chenodeoxycholic acid, it is recommended to monitor liver function tests once every 2–4 weeks.

For the purpose of prevention, it is necessary to maintain an optimal body mass index and a sufficient level of physical activity. A sedentary lifestyle contributes to the formation of gallstones. If the patient is likely to rapidly lose weight (more than 2 kg/week for 4 weeks or more), it is possible to prescribe ursodeoxycholic acid drugs at a dose of 8–10 mg/(kg·day) to prevent the formation of stones. Such an event prevents not only the formation of stones itself, but also the crystallization of cholesterol and an increase in the bile lithogenicity index.