Symptoms of gallstone disease, treatment without surgery and diet. Gallstone disease - description, causes, symptoms (signs), diagnosis, treatment Gallstone disease ICD

Gallstone disease (cholelithiasis) is the formation of stones in the gall bladder (cholecystolithiasis) and/or bile ducts (cholangiolithiasis, choledocholithiasis) due to metabolic disorders, accompanied by certain clinical symptoms and serious complications.

ICD-10 CODE

K80. Gallstone disease [cholelithiasis].

EPIDEMIOLOGY

Every fifth woman and every tenth man suffers from cholelithiasis (GSD). About a quarter of the population over 60 years of age has gallstones. A significant proportion of patients develop choledocholithiasis, obstructive jaundice, cholecystitis, cholangitis, strictures of the major duodenal papilla and other, sometimes life-threatening, complications.

More than 1,000,000 surgical interventions for cholelithiasis are performed annually in the world, and cholecystectomy is the most common abdominal operation in general surgical practice.

PREVENTION

Currently, there are no evidence-based studies on the prevention of cholelithiasis.

SCREENING

Ultrasound of the abdominal organs makes it possible to reliably detect cholelithiasis at the preclinical stage without the use of expensive invasive procedures.

CLASSIFICATION

Forms of clinical course of cholelithiasis:
. latent (stone-carrying);
. dyspeptic;
. painful.

Complications of cholelithiasis:
. acute cholecystitis;
. choledocholithiasis;
. stricture of the major duodenal papilla;
. obstructive jaundice;
. purulent cholangitis;
. biliary fistulas.

Nature of the stones:
. cholesterol;
. pigmented (black, brown);
. mixed.

ETIOLOGY AND PATHOGENESIS OF CHOLELITHIASIS

In the pathogenesis of stone formation, 3 main factors are important - oversaturation of bile with cholesterol, increased nucleation and decreased contractility of the gallbladder.

Oversaturation of bile with cholesterol.
With cholelithiasis, a change in the normal content of cholesterol, lecithin, and bile salts in the bile is observed. Cholesterol, practically insoluble in water, is found in bile in a dissolved state due to its micellar structure and the presence of bile salts and lecithin. In micellar structures there is always a certain limit of cholesterol solubility. The composition of bile is characterized by the lithogenicity index, which is determined by the ratio of the amount of cholesterol present in the blood being tested to its amount that can be dissolved at a given ratio of bile acids, lecithin, and cholesterol. Normally, the lithogenicity index is equal to one. If it is above one, cholesterol precipitates.


It has been established that the body of patients with significant obesity produces bile that is oversaturated with cholesterol. The secretion of bile acids and phospholipids in obese patients is greater than in healthy individuals with normal body weight, but their concentration is still insufficient to keep cholesterol in a dissolved state. The amount of secreted cholesterol is directly proportional to body weight and its excess, while the amount of bile acids largely depends on the state of the enterohepatic circulation and does not depend on body weight. As a result of this imbalance, obese people experience an oversaturation of bile with cholesterol.

Increased nucleation.
The first stage in the formation of stones in bile oversaturated with cholesterol is nucleation - a condensation and aggregation process in which gradually increasing microscopic crystals of cholesterol monohydrate are formed in the bile.


One of the most significant pronuclear factors is a mucin-glycoprotein gel, which, tightly adhering to the mucous membrane of the gallbladder, captures cholesterol microcrystals and adherent vesicles, which are a suspension of liquid crystals, supersaturated with cholesterol. Over time, as the contractility of the gallbladder decreases, hard crystals form from the vesicles. Calcium salts play a unique cementing role in this process. Calcium carbonate, calcium bilirubinate and calcium phosphate may also be the initial nuclei for cholesterol crystallization.

Decreased contractility of the gallbladder.
With normal contractility of the gallbladder, small cholesterol crystals can freely flow with the bile flow into the intestine before they are transformed into stones. Impaired contractility of the gallbladder (“bile reservoir”) predisposes to bile stagnation and stone formation. Violation of the coordinated work of the sphincters leads to dyskinesias of various types.
There are hyper- and hypotonic (atonic) dyskinesias of the bile ducts and gallbladder. With hypertensive dyskinesias, sphincter tone increases.


k, spasm of the common part of the sphincter of Oddi causes hypertension in the ducts and gallbladder. An increase in pressure leads to the entry of bile and pancreatic juice into the ducts and gallbladder, while the latter can cause the picture of enzymatic cholecystitis. A spasm of the cystic duct sphincter is possible, which leads to stagnation of bile in the bladder. With hypotonic (atonic) dyskinesias, the sphincter of Oddi relaxes and the contents of the duodenum reflux into the bile ducts, which can lead to their infection. Against the background of atony and poor emptying of the gallbladder, bile stagnation and an inflammatory process develop in it. Impaired evacuation of bile from the gallbladder and ducts is a necessary condition for stone formation in concentrated bile.

MAIN FEATURES OF PATHOLOGY

Stones can form both in the gallbladder (in the vast majority of cases) and in the ducts, which is much less common. Choledocholithiasis is usually caused by the migration of stones from the gallbladder into the bile ducts.

Based on their composition, it is customary to distinguish between cholesterol and pigment stones (brown and black).
Cholesterol stones- the most common type of gallstones - they consist either only of cholesterol, or it is their main component. Stones consisting only of cholesterol are usually large in size, white or with a yellowish tint, soft, crumble quite easily, and often have a layered structure.


Pure cholesterol stones contain more than 50% cholesterol and are somewhat more common than pure cholesterol stones. They are usually smaller in size and often multiple.
Pigment stones account for 10-25% of all gallstones in patients in Europe and the USA, but among the population of Asian countries their frequency is much higher. They are usually small in size, fragile, black or dark brown in color. With age, the frequency of their formation increases. Black pigment stones consist of either a black polymer - calcium bilirubinate, or polymer-like compounds of calcium, copper and a large amount of mucin glycoproteins. They do not contain cholesterol. They are more common in patients with liver cirrhosis, in chronic hemolytic conditions (hereditary spherocytic and sickle cell anemia; the presence of vascular prostheses, artificial heart valves, etc.).
Brown pigment stones consist predominantly of calcium salts of unconjugated bilirubin with the inclusion of varying amounts of cholesterol and protein. The formation of brown pigment stones is associated with infection, and microscopic examination reveals bacterial cytoskeletons.

CLINICAL PICTURE

There are several forms of cholelithiasis:
. Latent form (stone bearing).
A significant number of gallstone carriers do not have any complaints. Up to 60-80% of patients with stones in the gallbladder and up to 10-20% in the common bile duct do not have any associated disorders.


Opinion should be considered as a period of the course of cholelithiasis, since within 10 to 15 years after the discovery of “silent” gallstones, other clinical forms of cholelithiasis and its complications develop in 30-50% of patients.
. Dyspeptic form of cholelithiasis.
Complaints are associated with functional disorders of the digestive tract. Patients note a feeling of heaviness in the epigastrium, flatulence, unstable stools, heartburn, and bitterness in the mouth. Usually these sensations occur periodically, but can also be permanent. Complaints appear more often after a heavy meal, consumption of fatty, fried, spicy foods, and alcohol. In its pure form, the dyspeptic form is rare.
. Painful form of cholelithiasis.
The most common clinical form of symptomatic cholelithiasis (75% of patients). It occurs in the form of sudden and usually periodically recurring painful attacks of hepatic (biliary) colic. The mechanism of hepatic colic is complex and not fully understood. Most often, the attack is caused by a violation of the outflow of bile from the gallbladder or along the common bile duct (spasm of the sphincter of Oddi, obstruction by a stone, a lump of mucus).

Clinical manifestations of hepatic colic.
An attack of pain in the right hypochondrium can be triggered by an error in diet or physical activity. In many patients, pain occurs spontaneously even during sleep.


The attack begins suddenly, can last for hours, rarely more than a day. The pain is acute, paroxysmal, vaguely localized in the right hypochondrium and epigastrium (visceral pain). Irradiation of pain to the back or shoulder blade is caused by irritation of the endings of the branches of the spinal nerves that take part in the innervation of the hepatoduodenal ligament along the bile ducts. Nausea and vomiting mixed with bile often occur, bringing temporary relief. The noted symptoms may be associated with the presence of choledocholithiasis, cholangitis, ductal hypertension - the so-called choledochial colic.

In 1875 S.P. Botkin described cholecystic-cardiac syndrome, in which pain arising from hepatic colic spreads to the heart area, provoking an attack of angina. Patients with such manifestations can be treated for a long time by a cardiologist or therapist without effect. Usually, after cholecystectomy, complaints disappear.

The pulse may increase, but blood pressure does not change significantly. Increased body temperature, chills, and leukocytosis are not noted, since there is no inflammatory process (unlike an attack of acute cholecystitis). The pain usually increases over 15-60 minutes, and then remains almost unchanged for 1-6 hours. Subsequently, the pain gradually subsides or suddenly stops. The duration of an attack of pain for more than 6 hours may indicate the possible development of acute cholecystitis. Between attacks of colic, the patient feels quite well; 30% of patients do not report repeated attacks for a long time.


With repeated attacks of acute pain in the right hypochondrium and epigastrium ( painful torpid form of cholelithiasis) each episode should be considered an acute condition requiring active treatment in a surgical hospital.

A.M. Shulutko, V.G. Agadzhanov
Patients with cholelithiasis are advised to undergo regular dosed physical activity and a balanced diet. Diet No. 5 is prescribed with the exception of nutritional excesses of fatty foods. Meals are suggested by the hour.
At the onset of the disease, drug dissolution of stones is recommended. Chenodeoxycholic acid and ursodeoxycholic acid are used. Only cholesterol stones can be dissolved.
Conditions and indications for drug dissolution of stones:
— cholesterol stones, X-ray negative, up to 2 mm in size.
- a functioning gallbladder.
— occupancy of stones up to ½ volume.
— the diagnosis of the disease is no more than 2-3 years old.
— there are no stones in the ducts.
— patient’s consent to long-term treatment.


r /> Henofalk is used in capsules of 0.25 active ingredients, used before bedtime, in the following dosages:
- up to 60 kg - 3 capsules.
- up to 75 kg - 4 capsules.
– 75 – 90 kg – 5 capsules.
- more than 90 kg - 6 capsules.
The duration of treatment with henofalk ranges from several months to 2-3 years. The prescription of Ursofalk is also common - about 10 mg of the drug for every 10 kg of weight.
Cholecystectomy is a surgical procedure to remove the gallbladder. Cholecystectomy is performed laparotomically or laparoscopically. The operation options are cholecystolithotomy, papillosphincterotomy, cholecystostomy.
Indications for surgical intervention for cholelithiasis:
The presence of stones in the gall bladder, accompanied by a clinical picture of cholelithiasis;
Concomitant chronic cholecystitis (repeated biliary colic, non-functioning gallbladder);
Stones in the common bile duct;
Complications such as empyema, dropsy or gangrene of the gallbladder;
Perforation and penetration of the bladder with the formation of fistulas;
Development of Mirisi syndrome;
Suspicion of gallbladder cancer;
The presence of intestinal obstruction caused by a gallstone.

The cholelithiasis code according to ICD 10 stands for “cholelithiasis code according to the international classification of diseases 10.” The number at the end indicates the version of the document. It is periodically reviewed and adjusted. The latest edition is the tenth. Pathology codes are needed to maintain mortality statistics for various ailments. This, in turn, is necessary to prevent them and search for new treatment methods.

The international classification of diseases is a document used in world medical practice as a basis for collecting statistical data. Every 10 years, the World Health Organization reviews the ICD. Accordingly, 10 editions were approved. The last one is in effect.

For the first time, Dr. Savage proposed systematizing diseases in his scientific work “Methodology of Nosology”. The work was written in the 18th century. In the 19th century, William Farr from England expressed his opinion about the imperfection of the disease classification system existing at that time and proposed adopting a uniform classification for all countries.

In 1855, at the International Statistical Congress, 2 lists were presented, which were based on different classification principles.

Dr. Farr proposed dividing diseases into 5 categories:

  • systemic or organic pathologies;
  • epidemic diseases;
  • developmental diseases;
  • anatomical diseases;
  • diseases associated with violent acts.

At the same time, Dr. d’Espin proposed grouping diseases according to the nature of their manifestation. Congress decided to compromise and approved the list, which included 139 headings. The classification was later revised taking into account suggestions made by Dr. Farr.

In 1891, the International Statistical Institute received an order to classify all possible causes of mortality in one document. As a result, in 1893 the classification of causes of mortality was published.

In 1948, the classification was expanded to include conditions that are not fatal. Gallstone disease is one of these. Complications of the disease can lead to death. In its original form, the pathology is painful, but not life-threatening.

The purpose of the ICD is to:

  1. Studying and comparing data on the level of morbidity and mortality in individual regions over time.
  2. Used by all medical institutions to maintain a unified record of morbidity and mortality. This makes it easier to plan the work of medical centers.
  3. Used to research and study the causes that lead to illness or death of patients.
  4. Ensuring a unified approach to morbidity and mortality among the population.

Since 2012, the current classifier has been revised in order to qualitatively reflect medical progress.

Place of cholelithiasis in ICD 10

In ICD 10, gallstone pathology is designated as K80. However, the disease has many varieties, differing in severity and treatment methods. Other diseases of the biliary tract according to ICD 10 also have code 80.

Doctors call cholelithiasis a condition in which there are stones in the organ or its ducts that impede the functioning of the digestive system. Conglomerates are formed from cholesterol in the liver secretion, the pigment bilirubin contained in it and calcium salts. As long as the stones do not interfere with the release of bile, the pathology occurs without visible symptoms and does not cause inflammation. In most cases, gallstone pathology occurs in conjunction with a disruption of the pancreas. The organs have a common duct.

In ICD 10, certain symptoms are assigned to cholelithiasis:

  • yellowing of the skin and mucous membranes;
  • painful sensations in the area of ​​the right hypochondrium;
  • nausea, which is sometimes combined with vomiting that does not bring relief;
  • a feeling of bitterness in the mouth;
  • bloating;
  • stool disorder.

According to the international classification, the development of cholelithiasis largely depends on the age and gender of a person. In women, the disease is diagnosed more often, and with age, the likelihood of developing pathology increases.

There are many reasons for the development of gallstone disease, but the main one is nutritional disorders. People whose diet is dominated by meat and fats of animal origin suffer.

Other causes of gallstone disease, according to ICD 10, include:

  • hormonal disorders in the body;
  • hereditary predisposition;
  • inactive lifestyle;
  • being overweight;
  • strict diets, especially if they are resorted to frequently;
  • inflammatory processes in the organ;
  • previous injuries;
  • diseases of the liver or biliary tract;
  • the presence of helminths in the body;
  • diabetes.

GSD has several stages of development:

  1. Initial. The process of stagnation of bile and changes in its chemical composition begins, but there are no stones in the organ. There are no specific symptoms. The diagnosis can be made after a biochemical analysis of bile.
  2. Stage of stone formation. The stones are small in size, resemble sand, and do not cause discomfort.
  3. Exacerbation of the disease. Typically, patients do not pay attention to the first signs of the disease for a long time, considering them insignificant. A doctor is consulted when cholelithiasis worsens and becomes chronic. At the same time, the clinical picture of the pathology is clearly expressed.
  4. Complication. As a rule, the disease can be cured at the third stage, although there are situations when gallstone disease still leads to the development of complications, for example, cholangitis. This is inflammation of the bile ducts.

In order for the doctor to make an accurate diagnosis, he:

  • conducts a patient interview;
  • orders a blood test;
  • refers for ultrasound examination;
  • performs cholecystography;
  • prescribes computed tomography or magnetic resonance imaging.

Only after a comprehensive diagnosis can the doctor prescribe treatment. It mainly involves surgical removal of stones. The stones are excised along with the bladder. Additionally, you need to adhere to a certain diet.

Features of the coding of cholelithiasis

According to ICD 10, gallstone disease refers to diseases of the digestive system. The classification of pathology includes subparagraphs, thanks to which the patient’s condition can be specified.

According to ICD 10, gallstone disease is divided into diseases:

  1. K80.0 – acute inflammation of an organ associated with the presence of stones in it.
  2. K80.1 – combination of cholelithiasis with cholecystitis.
  3. K80.2 – detection of stones in the organ, but without inflammation.
  4. K80.3 – an inflammatory process in the organ associated with the formation of stones.
  5. K80.4 – the presence of cholecystitis in combination with stones in the ducts. The latter are present both in the liver and outside it. Ducts approaching the bladder and pancreas.
  6. K80.5 – detection of stones in the ducts, without their inflammation.
  7. K80.8 – other forms (this also includes dyskinesia in children). Gallstone disease can also affect a child. GSD accounts for 1% of the total number of pathologies of the digestive system in adolescents.

Doctors note that it is possible to avoid complications of cholelithiasis and quickly cope with the problem when the disease is detected at the initial stage of development.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Archive - Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2007 (Order No. 764)

Chronic cholecystitis (K81.1)

general information

Short description

Cholecystitis- an inflammatory disease that causes damage to the wall of the gallbladder, the formation of stones in it and motor-tonic disorders of the biliary system.

Protocol code:H-S-007 "Cholelithiasis, chronic cholecystitis with cholecystectomy"

Profile: surgical

Stage: hospital
ICD-10 code(s):

K80.2 Gallstones without cholecystitis

K80 Gallstone disease (cholelithiasis)

K81 Cholecystitis


Classification

Risk factors and groups

Cirrhosis of the liver;
- infectious diseases of the biliary tract;
- hereditary blood diseases (sickle cell anemia);
- elderly age;
- pregnant women;
- obesity;
- medications that lower blood cholesterol levels actually increase cholesterol levels in bile;
- rapid weight loss;
- stagnation of bile;
- hormone replacement therapy in postmenopause;
- women taking birth control pills.

Diagnostics

Diagnostic criteria: constant pain in the epigastrium radiating to the right shoulder and between the shoulder blades, which intensifies and lasts from 30 minutes to several hours. Nausea and vomiting, belching, flatulence, aversion to fatty foods, yellowish tint to the skin and whites of the eyes, low-grade fever.


List of main diagnostic measures:

1. General blood test (6 parameters).

2. General urine analysis.

3. Determination of glucose.

4. Determination of capillary blood clotting time.

5. Determination of blood group and Rh factor.

7. Histological examination of tissue.

8. Fluorography.

9. Microreaction.

11. HbsAg, Anti-HCV.

12. Determination of bilirubin.

13. Ultrasound of the abdominal organs.

14. Ultrasound of the liver, gall bladder, pancreas.

15. Esophagogastroduodenoscopy.

16. Consultation with a surgeon.


List of additional diagnostic measures:

1. Duodenal sounding (ECD or other options).

2. Computed tomography.

3. Magnetic resonance cholangiography.

4. Cholescintigraphy.

5. Endoscopic retrograde cholangiopancreatography.

6. Bacteriological, cytological and biochemical study of duodenal contents.


Treatment abroad

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Treatment

Treatment tactics


Treatment goals: surgical removal of the gallbladder.


Treatment

Cholecystectomy, intraoperative drainage according to Pinovsky and in the postoperative period - ERCP, PST.
Antibacterial therapy for the prevention of postoperative purulent complications. Dressings. If stones are detected in the gallbladder, surgical intervention is performed to prevent possible complications.

After preparing the patient, the operation begins with laparoscopy. If the hepatoduodenal zone is intact, the operation is performed laparoscopically.


Indications for cholecystectomy using laparoscopic technique:

Chronic calculous cholecystitis;

Polyps and cholesterosis of the gallbladder;

Acute cholecystitis (in the first 2-3 days from the onset of the disease);

Chronic acalculous cholecystitis;

Asymptomatic cholecystolithiasis (large and small stones).


If the common bile duct is enlarged or there are stones in it, laparotomy and classic cholecystectomy are performed. In the postoperative period, antibacterial and symptomatic therapy is carried out.

Emergency surgery is indicated for symptoms of peritonitis and a tense, enlarged gallbladder.

Early cholecystectomy compared with delayed cholecystectomy does not have a significant difference in terms of complications, but early cholecystectomy reduces hospital stay by 6-8 days.


Antibacterial treatment options using one of them:

1. Ciprofloxacin orally, 500-750 mg 2 times a day, for 10 days.

2. Doxycycline orally or intravenously. On the 1st day, 200 mg/day is prescribed, on subsequent days 100-200 mg/day, depending on the severity of the disease.

Duration of taking the drug is up to 2 weeks.

4. For the treatment and prevention of mycosis during long-term massive antibiotic therapy - itraconazole oral solution 400 mg/day, for 10 days.

5. Anti-inflammatory drugs 480-960 mg 2 times a day with an interval of 12 hours.


Symptomatic drug therapy (used according to indications):

3. Multienzyme drug taken before meals, 1-2 doses, for 2-3 weeks. Therapy can be adjusted depending on the clinical effect and the results of studies of duodenal contents.

4. Antacid drug, taken one dose 1.5-2 hours after meals.


List of essential medications:

1. *Trimepyridine hydrochloride injection solution in ampoule 1%, 1 ml

2. *Cefuroxime 250 mg, 500 mg tablet.

3. *Sodium chloride 0.9% - 400 ml

4. *Glucose solution for infusion 5%, 10% in a bottle of 400 ml, 500 ml; solution 40% in ampoule 5 ml, 10 ml

5. *Itraconazole oral solution 150 ml - 10 mg\ml

6. *Diphenhydramine solution for injection 1% 1 ml

7. Polividone 400 ml, fl.

8. *Aminocaproic acid 5% - 100ml, fl.

9. *Metronidazole solution 5mg/ml 100ml

11. *Drotaverine solution for injection 40 mg/2ml

12. *Thiamin injection solution 5% in 1 ml ampoule

13. *Pyridoxine 10 mg, 20 mg tablet; injection solution 1%, 5% in 1 ml ampoule

14. *Riboflavin 10 mg tablet.

  • Treatment goals
    • Quick relief from the symptoms of biliary colic.
    • Prevention of complications of cholelithiasis and timely surgical removal of stones and gallbladder in case of recurrent biliary colic.
    • Prevention of recurrence of biliary colic after the first attack.
    • Prevention of the development of symptoms of cholelithiasis in asymptomatic stone carriers.
  • Treatment methods

    The choice of treatment method for patients with gallstone disease is determined by the clinical course of the disease.

    Treatment methods for the disease can be divided into 3 groups:

    • Conservative and non-medicinal treatment - diet therapy and gene therapy.
    • Minimally invasive treatment methods.
    • Surgery.
    • Diet therapy
    • Chenotherapy

      Chenotherapy consists of the use of medicinal oral litholysis with preparations of bile acids of cholesterol non-calcified single stones, no more than 15 mm in size (with preserved contractile function of the gallbladder).


      Bile acid preparations (deoxycholic acid derivatives) are used to dissolve stones:

      • ursodeoxycholic acid (UDCA (Ursosan, Ursofalk)).

        UDCA acid inhibits the absorption of cholesterol in the intestine and promotes the transfer of cholesterol from stones into bile.

        UDCA is prescribed orally at a dose of 10 mg/kg/day, the entire dose once in the evening before bedtime, washed down with liquids (water, tea, juices, milk).

      • Chenodeoxycholic acid (CDCA).

        CDCA inhibits the synthesis of cholesterol in the liver and also promotes the dissolution of cholesterol stones.

        CDCA is prescribed orally at a dose of 15 mg/kg/day, the entire dose once in the evening before bedtime, washed down with liquids (water, tea, juices, milk).

      The duration of treatment with one of these drugs ranges from 6 to 24 months with continuous use.

      Due to the fact that the points of action of these acids are different, the combined use of these drugs is most effective, but in this case each drug is used in a lower dose than usual (CDCA orally 7-8 mg/kg/day + UDCA orally 7-8 mg /kg/day once in the evening).

      Before starting treatment, the patient should be informed about the recurrence rate of stone formation after treatment, which is about 50%, as well as the duration of therapy, which reaches 2 years.

      Treatment is usually well tolerated, except in cases of diarrhea. In this case, the dose is reduced and, after stool normalization, gradually increased again. When using CDCA, diarrhea develops in 30% of patients, when taking UDCA - in 2%, when combining two drugs - in 5%.

      During treatment, 2-5% of patients experience an increase in the activity of liver enzymes (AST, ALT, GGTP), so during the first 3 months of treatment it is necessary to monitor enzyme levels every 4 weeks.

      Treatment with bile acids does not prevent biliary colic and complications of cholelithiasis. Since the dissolution of stones occurs on average in 18 months, during the treatment period colic and their complications may develop (blockage of the cystic duct, obstructive jaundice, acute cholecystitis, cholangitis, pancreatitis, calcification (calcification) of stones), the frequency of which does not exceed that in patients who are not receiving medications.

      Oral litholytic therapy does not increase the likelihood of surgical treatment, since indications for surgery arise within 1 to 2 years after the first attack of biliary colic and in 10% of patients not treated with bile acids. The risk of an unfavorable outcome of the operation when using litholytic treatment in cases where the patient has to be operated on does not increase.

      This method is available for a very small group of patients with uncomplicated disease (no more than 20% of patients).

  • Evaluation of the effectiveness of conservative treatment

    Treatment is carried out under control of the condition of the stones according to ultrasound every 3-6 months. In the absence of signs of a decrease in the number and size of stones after 1 year (according to some authors after 6 months), treatment should be stopped.

    The effectiveness of treatment turns out to be quite high, and with proper selection of patients, in 60-70% of them, complete dissolution of stones is observed after 18-24 months. After completion of treatment, control ultrasounds continue to be performed every 6 months. for timely diagnosis of recurrent stone formation.

  • Treatment tactics
    • The first episode of biliary colic is not an indication for surgery, since the risk of developing recurrent colic over subsequent years is low. In 30% of patients, recurrent colic does not develop over the next 10 years or more. In such patients, the risk of developing complications of cholelithiasis is no higher than in persons operated on after the first colic, so wait-and-see management is considered justified.
    • In case of recurrent cholelithiasis, surgical treatment is indicated, since the risk of complications and the risk of death after repeated colic increases 4 times.
    • In case of complicated cholelithiasis, including acute and chronic cholecystitis, rapid sanitation of the biliary tract and cholecystectomy are indicated.
    • With cholecystolithiasis, about 30% of patients with cholelithiasis can be subjected to litholytic therapy. Oral therapy with bile acids is indicated in cases where other types of treatment are contraindicated for patients, as well as when the patient does not consent to surgery. The success of treatment is higher in patients with early detection of cholelithiasis and significantly lower in patients with a long history of the disease due to calcification of stones. With preserved contractile function of the gallbladder, the prognosis for the success of therapy is much better.
    • One of the main conditions for the effectiveness of litholytic therapy is the determination of the composition of gallstones. A prerequisite for litholytic therapy is free patency of the bile ducts.
    • The effectiveness of treatment is monitored using ultrasound, which must be performed every 3-6 months. The absence of positive dynamics after 1 year (according to some authors, 6 months) of therapy is the basis for its cancellation and decision on the issue of surgical treatment.

Cholelithiasis is a disease of the gallbladder and bile ducts with the formation of stones. Although, the correct name of the medical term is “cholelithiasis” - ICD-10 code: K80. The disease is complicated by poor liver function, hepatic colic, cholecystitis (inflammation of the gallbladder) and may result in obstructive jaundice with the need for surgery to remove the gallbladder.

Today we will look at the causes, symptoms, signs, exacerbation, treatment of cholelithiasis without surgery using medical and folk remedies, what to do in case of an attack of pain, when surgery is needed. We’ll especially talk about the patients’ nutrition (diet), menus, what foods can and cannot be eaten during treatment without surgery and after it.

What it is?

Gallstone disease is a pathological process in which stones (calculi) form in the gallbladder and ducts. Due to the formation of stones in the gall bladder, the patient develops cholecystitis.

How gallstones form

The gallbladder is a reservoir for bile produced by the liver. The movement of bile along the biliary tract is ensured by the coordinated activity of the liver, gallbladder, common bile duct, pancreas, and duodenum. This ensures the timely entry of bile into the intestines during digestion and its accumulation in the gallbladder on an empty stomach.

The formation of stones in it occurs due to changes in the composition and stagnation of bile (dyscholia), inflammatory processes, motor-tonic disorders of bile secretion (dyskinesia).

There are cholesterol (up to 80-90% of all gallstones), pigment and mixed stones.

  1. The formation of cholesterol stones is facilitated by the oversaturation of bile with cholesterol, its precipitation, and the formation of cholesterol crystals. If the motility of the gallbladder is impaired, the crystals are not excreted into the intestines, but remain and begin to grow.
  2. Pigment (bilirubin) stones appear as a result of increased breakdown of red blood cells during hemolytic anemia.
  3. Mixed stones are a combination of both forms. Contains calcium, bilirubin, cholesterol.

They occur mainly in inflammatory diseases of the gallbladder and bile ducts.

Risk factors

There are several reasons for the occurrence of cholelithiasis:

  • excess secretion of cholesterol into bile
  • decreased secretion of phospholipids and bile acids into bile
  • bile stagnation
  • biliary tract infection
  • hemolytic diseases.

Most gallstones are mixed. They include cholesterol, bilirubin, bile acids, proteins, glycoproteins, various salts, and trace elements. Cholesterol stones contain mainly cholesterol, have a round or oval shape, a layered structure, a diameter of 4–5 to 12–15 mm, and are localized in the gallbladder.

  1. Cholesterol-pigment-calcareous stones are multiple, have edges, and have different shapes. They vary significantly in quantity - tens, hundreds and even thousands.
  2. Pigment stones are small in size, multiple, hard, fragile, completely homogeneous, black in color with a metallic tint, located both in the gallbladder and in the bile ducts.
  3. Calcium stones consist of various calcium salts, have a bizarre shape, have spiky processes, and are light or dark brown in color.

Epidemiology

According to numerous publications throughout the 20th century, especially its second half, there was a rapid increase in the prevalence of cholelithiasis, mainly in industrialized countries, including Russia.

Thus, according to a number of authors, the incidence of cholelithiasis in the former USSR almost doubled every 10 years, and stones in the bile ducts were detected at autopsies in every tenth person who died, regardless of the cause of death. At the end of the 20th century, more than 5 million and in the USA more than 15 million patients with cholelithiasis were registered in Germany, and about 10% of the adult population suffered from this disease. According to medical statistics, cholelithiasis occurs in women much more often than in men (ratio from 3:1 to 8:1), and with age the number of patients increases significantly and after 70 years reaches 30% or more in the population.

The increasing surgical activity for cholelithiasis observed throughout the second half of the 20th century has led to the fact that in many countries the frequency of biliary tract operations has surpassed the number of other abdominal operations (including appendectomy). Thus, in the USA in the 70s, more than 250 thousand cholecystectomies were performed annually, in the 80s - more than 400 thousand, and in the 90s - up to 500 thousand.

Classification

Based on the characteristics of the disease accepted today, the following classification is distinguished in accordance with the stages relevant to it:

  1. Stone formation is a stage that is also defined as latent stone formation. In this case, there are no symptoms of gallstone disease, but the use of instrumental diagnostic methods makes it possible to determine the presence of stones in the gallbladder;
  2. Physico-chemical (initial) stage - or, as it is also called, the pre-stone stage. It is characterized by changes occurring in the composition of bile. There are no special clinical manifestations at this stage; detection of the disease at the initial stage is possible, for which a biochemical analysis of bile is used to determine the characteristics of its composition;
  3. Clinical manifestations are a stage whose symptoms indicate the development of an acute or chronic form of calculous cholecystitis.

In some cases, a fourth stage is also distinguished, which consists of the development of complications associated with the disease.

Symptoms of gallstone disease

In principle, cholelithiasis can occur for a very long time without any symptoms or manifestations. This is explained by the fact that the stones in the early stages are small, do not clog the bile duct and do not injure the walls. The patient may not even suspect that he has this problem for a long time. In these cases, they usually talk about stone-carrying. When gallstone disease itself makes itself felt, it can manifest itself in different ways.

Among the first symptoms of the disease, heaviness in the abdomen after eating, stool disturbances (especially after eating fatty foods), nausea and moderate jaundice should be noted. These symptoms may appear even before severe pain in the right hypochondrium - the main symptom of cholelithiasis. They are explained by unexpressed disturbances in the outflow of bile, which makes the digestion process worse.

The most typical symptoms and signs of cholelithiasis are:

  1. Temperature increase. An increase in temperature usually indicates acute cholecystitis, which often accompanies cholelithiasis. An intense inflammatory process in the area of ​​the right hypochondrium leads to the release of active substances into the blood that contribute to a rise in temperature. Prolonged pain after colic accompanied by fever almost always indicates acute cholecystitis or other complications of the disease. A periodic increase in temperature (wavy) with a rise above 38 degrees may indicate cholangitis. However, in general, fever is not a mandatory symptom of gallstone disease. The temperature may remain normal even after severe, prolonged colic.
  2. Pain in the right hypochondrium. The most typical manifestation of cholelithiasis is the so-called biliary (biliary, hepatic) colic. This is an attack of acute pain, which in most cases is localized at the intersection of the right costal arch and the right edge of the rectus abdominis muscle. The duration of an attack can vary from 10–15 minutes to several hours. At this time, the pain can be very severe, radiating to the right shoulder, back or other areas of the abdomen. If an attack lasts more than 5–6 hours, then you should think about possible complications. The frequency of attacks may vary. Often, about a year passes between the first and second attack. However, in general, they become more frequent over time.
  3. Fat intolerance. In the human body, bile is responsible for the emulsification (dissolution) of fats in the intestines, which is necessary for their normal breakdown, absorption and assimilation. With cholelithiasis, stones in the cervix or bile duct often block the path of bile to the intestines. As a result, fatty foods are not broken down normally and cause intestinal disturbances. These disorders can manifest as diarrhea (diarrhea), accumulation of gases in the intestines (flatulence), and mild abdominal pain. All these symptoms are nonspecific and can occur in various diseases of the gastrointestinal tract (gastrointestinal tract). Intolerance to fatty foods can also occur at the stone-carrying stage, when other symptoms of the disease are still absent. At the same time, even a large stone located at the bottom of the gallbladder may not block the flow of bile, and fatty foods will be digested normally.
  4. Jaundice. Jaundice occurs due to stagnation of bile. The pigment bilirubin is responsible for its appearance, which is normally secreted with bile into the intestines, and from there is excreted from the body with feces. Bilirubin is a natural metabolic product. If it ceases to be excreted in the bile, it accumulates in the blood. This is how it spreads throughout the body and accumulates in tissues, giving them a characteristic yellowish tint. Most often, the sclera of the eyes turn yellow in patients first, and only then the skin. In fair-skinned people, this symptom is more noticeable, but in dark-skinned people, unexpressed jaundice can be missed even by an experienced doctor. Often, simultaneously with the appearance of jaundice, patients' urine also darkens (dark yellow, but not brown). This is explained by the fact that the pigment begins to be released from the body through the kidneys. Jaundice is not a mandatory symptom of calculous cholecystitis. Also, it does not appear only with this disease. Bilirubin can also accumulate in the blood due to hepatitis, liver cirrhosis, some hematological diseases or poisoning.

In general, the symptoms of cholelithiasis can be quite varied. There are various stool disorders, atypical pain, nausea, and periodic bouts of vomiting. Most doctors are aware of this variety of symptoms, and just in case, they prescribe an ultrasound of the gallbladder to exclude cholelithiasis.

Attack of cholelithiasis

An attack of cholelithiasis usually means biliary colic, which is the most acute and typical manifestation of the disease. Stone carriage does not cause any symptoms or disorders, and patients usually do not attach importance to mild digestive disorders. Thus, the disease proceeds latently (hidden).

Biliary colic usually appears suddenly. Its cause is a spasm of smooth muscles located in the walls of the gallbladder. Sometimes the mucous membrane is also damaged. Most often this happens if the stone moves and gets stuck in the neck of the bladder. Here it blocks the outflow of bile, and bile from the liver does not accumulate in the bladder, but flows directly into the intestines.

Thus, an attack of cholelithiasis usually manifests itself as characteristic pain in the right hypochondrium. At the same time, the patient may experience nausea and vomiting. Often an attack occurs after sudden movements or exertion, or after eating a large amount of fatty food. Once during an exacerbation, stool discoloration may be observed. This is explained by the fact that pigmented (colored) bile from the gallbladder does not enter the intestine. Bile from the liver flows only in small quantities and does not give intense color. This symptom is called acholia. In general, the most typical manifestation of an attack of cholelithiasis is characteristic pain, which will be described below.

Diagnostics

Identification of symptoms characteristic of hepatic colic requires consultation with a specialist. The physical examination carried out by him means identifying symptoms characteristic of the presence of stones in the gallbladder (Murphy, Ortner, Zakharyin). In addition, a certain tension and soreness of the skin is detected in the area of ​​the abdominal wall muscles within the projection of the gallbladder. The presence of xanthomas (yellow spots on the skin formed against the background of a disorder in the body's lipid metabolism) is also noted, and yellowness of the skin and sclera is noted.

The results of a general blood test determine the presence of signs indicating nonspecific inflammation at the stage of clinical exacerbation, which include, in particular, a moderate increase in ESR and leukocytosis. A biochemical blood test reveals hypercholesterolemia, as well as hyperbilirubinemia and increased activity characteristic of alkaline phosphatase.

Cholecystography, used as a method for diagnosing cholelithiasis, determines the enlargement of the gallbladder, as well as the presence of calcareous inclusions in the walls. In addition, in this case, the stones with lime inside are clearly visible.

The most informative method, which is also the most common in the study of the area of ​​interest to us and for the disease in particular, is ultrasound of the abdominal cavity. When examining the abdominal cavity in this case, accuracy is ensured regarding the identification of the presence of certain echo-proof formations in the form of stones in combination with pathological deformations to which the walls of the bladder are exposed during the disease, as well as with changes that are relevant in its motility. Signs indicating cholecystitis are also clearly visible on ultrasound.

Visualization of the gallbladder and ducts can also be performed using MRI and CT techniques for this purpose in specifically indicated areas. Scintigraphy, as well as endoscopic retrograde cholangiopancreatography, can be used as an informative method indicating disturbances in the processes of bile circulation.

Drug treatment of gallstone disease

Treatment of cholelithiasis without surgery is used in the presence of cholesterol gallstones (X-ray negative) up to 15 mm in size with preserved contractility of the gallbladder and patency of the cystic duct.

Contraindications for drug dissolution of gallstones:

  • inflammatory diseases of the small and large intestines;
  • obesity;
  • pregnancy;
  • “disabled” - non-functioning gallbladder;
  • acute inflammatory diseases of the gallbladder and biliary tract;
  • stones with a diameter of more than 2 cm;
  • liver disease, diabetes mellitus, peptic ulcer of the stomach and duodenum, chronic pancreatitis;
  • pigment or carbonate stones;
  • gallbladder cancer;
  • multiple stones that 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 probability of relapse after the stones dissolve is 50%. The dosage of the drug and duration of administration are determined only by a general practitioner or gastroenterologist. Conservative treatment is possible only under the supervision of a doctor.

Shock wave cholelithotrepsia is treatment by crushing large stones into small fragments using shock waves, followed by taking bile acid preparations (ursodeoxycholic acid). The chance of relapse is 30%.

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

Treatment with folk remedies for cholelithiasis

I will give an example of several recipes for dissolving stones. There are a large number of them.

  1. Green tea. Drink as a preventive measure against cholelithiasis, since green tea prevents stone formation.
  2. Lingonberry leaves. The leaves of this plant help dissolve gallstones. Pour a glass of boiling water over 1 tablespoon of dried lingonberry leaves and leave for 20-30 minutes. Take 2 tablespoons 4-5 times a day.
  3. Ivan-tea or narrow-leaved willowherb. Brew 2 tablespoons of dry fireweed leaves in a thermos, pour boiling water (0.5 l). Leave for 30 minutes. Drink 100 ml of tea an hour before meals three times a day for six months. You can infuse the same brew as long as the tea has color. Consult a doctor before use, as stones may be dislodged.

The main thing in treating cholelithiasis with folk remedies is to make sure that you have cholesterol stones that can be dissolved. To do this, you need to undergo an ultrasound (the stones are visible) and an x-ray (cholesterol stones are not visible).

After this, visit a herbalist and choose the most effective combination of herbs for your case. In parallel with the use of folk remedies, it is necessary to adhere to the principles of rational nutrition - sometimes only a change in diet allows you to get rid of small cholesterol stones. It is also necessary to devote time to physical activity - walking, a little exercise in the morning - that is, move more.

Diet for gallstone disease

It is necessary to limit or exclude fatty, high-calorie, cholesterol-rich foods from the diet, especially if there is a hereditary predisposition to gallstone disease. Meals should be frequent (4-6 times a day), in small portions, which helps reduce stagnation of bile in the gallbladder. Food should contain a sufficient amount of dietary fiber from vegetables and fruits. You can add food bran (15g 2-3 times a day). This reduces the lithogenicity (propensity to form stones) of bile.

The therapeutic diet for gallstone disease lasts from 1 to 2 years. Following a diet is the best prevention of exacerbations of cholelithiasis, and if you do not adhere to it, severe complications may develop.

The consequences of non-compliance include: the occurrence of atherosclerosis, the appearance of constipation, which is dangerous due to stones in the bladder, increased load on the gastrointestinal tract and increased bile density. A therapeutic diet will help cope with excess weight, improve intestinal microflora and protect the immune system. As a result, a person’s mood improves and sleep normalizes.

In severe cases, non-compliance with the diet leads to ulcers, gastritis, and colitis. If you want to recover from pathology without surgery, then diet is a primary requirement.

Operation

Patients should undergo elective surgery before or immediately after the first attack of biliary colic. This is due to the high risk of complications.

After surgical treatment, it is necessary to follow an individual dietary regimen (frequent, small meals with the limitation or exclusion of individually intolerable foods, fatty, fried foods), adherence to a work and rest regime, and physical exercise. Avoid drinking alcohol. Spa treatment after surgery is possible, subject to stable remission.

Complications

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 the inflammation spreads to the abdominal organs and peritoneum, the patient develops peritonitis. As a result, infectious-toxic shock and multiple organ failure can 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.

Prevention

To prevent the disease, it is useful to carry out the following activities:

  • do not practice long-term therapeutic fasting;
  • To prevent cholelithiasis, it is useful to drink enough fluid, at least 1.5 liters per day;
  • in order not to provoke the movement of stones, avoid work associated with prolonged stay in an inclined position;
  • follow a diet, normalize body weight;
  • increase physical activity, give the body more movement;
  • eat more often, every 3-4 hours, to cause regular emptying of the bladder from accumulated bile;
  • Women should limit their intake of estrogen; this hormone promotes the formation of stones or their enlargement.

For the prevention and treatment of cholelithiasis, it is useful to include in the daily diet a small amount (1-2 tsp) of vegetable oil, preferably olive oil. Sunflower is only 80% digestible, while olive oil is completely digestible. It is also more suitable for frying as it produces fewer phenolic compounds.

The intake of vegetable fat stimulates the activity of the bile bladder, as a result of which it is able to empty itself at least once a day, preventing congestion and the formation of stones.

To normalize metabolism and prevent cholelithiasis, it is worth including magnesium in your diet. The microelement stimulates intestinal motility and bile production, removes cholesterol. In addition, sufficient zinc intake is necessary for the production of bile enzymes.

If you have gallstone disease, it is better to stop drinking coffee. The drink stimulates the contraction of the bladder, which can cause blockage of the duct and a subsequent attack.