Gallstone

Introduction Gallstones are stones that occur in the gallbladder. Mainly for cholesterol stones and mixed stones mainly composed of cholesterol stones. Often coexist with acute cholecystitis. After the stone is formed in the gallbladder, it can stimulate the gallbladder mucosa, which can not only cause chronic inflammation of the gallbladder, but also cause secondary infection when the stone is invaded in the neck of the gallbladder or the cystic duct, leading to acute inflammation of the gallbladder. Due to the chronic stimulation of gallbladder mucosa by stones, it may also lead to the occurrence of gallbladder cancer. It is reported that the incidence of gallbladder cancer can reach 1-2%.

Cause

The incidence of gallstones is related to age, gender, obesity, fertility, race and diet, as well as medication history, surgical history and other diseases.

1. Age of onset: Most epidemiological studies have shown that the incidence of gallstones increases with age. The disease is rare in childhood and may be associated with hemolysis or congenital biliary disease. According to a survey, the 5-year incidence rate of 40-69 years old is 4 times that of the low-age group, and the dividing line between high-incidence and low-incidence is 40 years old. Although there are some differences in reports from various countries, the peak age of onset is 40 to 50 years old.

2. Sex differences in the incidence: In recent years, the ratio of male and female onset of ultrasound diagnosis is about 1:2. The difference in sex ratio is mainly reflected in the incidence of cholesterol stones. There is no significant gender difference in the incidence of gallstones in the gallbladder. High levels of cholesterol in women may be associated with estrogen lowering bile flow, increasing cholesterol secretion in bile, lowering total bile acid volume and activity, and progesterone affecting gallbladder motility and causing bile stasis.

3. Relationship between onset and obesity: Clinical and epidemiological studies have shown that obesity is an important risk factor for the incidence of cholesterol gallstones in the gallbladder, and the incidence of obese people is three times that of normal weight. The reason why obese people are more susceptible to gallstones is that their cholesterol synthesis is absolutely increased, or the relative increase in bile acids and phospholipids makes the cholesterol supersaturated.

4. Relationship between onset and fertility: Pregnancy can promote the formation of gallstones, and the number of pregnancies is positively correlated with the incidence of gallstones. This view has been proved by clinical and epidemiological studies. The causes of stones in pregnancy are: 1 The increase in estrogen during pregnancy changes the bile composition and increases the saturation of cholesterol in the bile. 2 The gallbladder emptying during pregnancy is slow, B-ultrasound shows that when the pregnant woman is fasting, the gallbladder volume increases, the residual volume increases after contraction, and the gallbladder contraction rate decreases. 3 changes in body weight during pregnancy and postpartum also affect bile composition, change the intestinal liver circulation of bile acids, and promote the formation of cholesterol crystals.

5. Regional differences in incidence: There are certain differences in the incidence rates among different countries and regions. The prevalence of cholelithiasis is high in Western Europe, North America and Australia, and cholelithiasis is rare in many places in Africa. The gallbladder in Beijing, Shanghai, Northwest China and North China is rare in China. The incidence of stones is high. The types of gallstones vary from country to country, with cholesterol stones in Sweden and Germany, and calcium carbonate stones in the UK.

6. Incidence and dietary factors: Eating habits are the main factors affecting the formation of gallstones. The incidence of gallstones in foods with refined food and high cholesterol is significantly increased. Because refined carbohydrates increase bile cholesterol saturation. With the improvement of living standards in China, the incidence of gallstones has occupied the main position of cholelithiasis, and it is mainly composed of cholesterol stones.

7. Incidence and genetic factors: The difference in the incidence of gallstones in the race also suggests that genetic factors are one of the pathogenesis of cholelithiasis. The incidence of gallstones is high in people with Indian genes. Studies on single-oval twins have shown that the risk of gallstones in the relatives of patients with cholelithiasis is also high, and the incidence of cholelithiasis in the family is also advanced, so support for cholelithiasis may have a genetic predisposition.

8. Other factors: The incidence of gallstones is also associated with cirrhosis, diabetes, hyperlipidemia, parenteral nutrition, surgical trauma and the use of certain drugs. For example, the incidence of cholelithiasis in patients with cirrhosis is three times that of no cirrhosis, and the incidence of cholelithiasis in diabetic patients is twice that of non-diabetic patients.

The main components of gallstones are mainly cholesterol, and the cause of gallstone formation has not yet been fully understood. At present, it is closely related to various factors such as lipid metabolism, nucleation time, gallbladder motor function, and bacterial gene fragments.

an examination

Simple gallbladder stones generally do not have jaundice and liver dysfunction, so there is no positive test results for laboratory tests on jaundice and liver function.

Imaging examination is currently the main means of diagnosis of gallstone disease. Ultrasound is often the first line of examination. It can be found in gallbladder stones, gallbladder wall thickening, and gallbladder lack of contraction. The results are often accurate and reliable. Other methods of inspection often determine whether to use it further based on the results of the ultrasound examination.

On X-ray films, about 20% of gallstones are positive because of high calcium content. Due to the low positive rate of stones, X-ray films in the hepatobiliary area have not been used as clinical diagnostic requirements. However, the X-ray film can show the soft tissue shadow of the enlarged gallbladder and inflammatory mass and the gas shadow around the gallbladder and around the gallbladder in the case of gas cholecystitis. In addition, some indirect X-ray signs often contribute to the diagnosis of acute cholecystitis: 1 the expansion of the small intestine below the gallbladder, inflation and other reflex intestinal complications. 2 The soft tissue shadow of the gallbladder area increases. 3 signs of irritation of the peritoneum, such as the peritoneal fat line on the right side is blurred or disappeared, and the right diaphragm is elevated. 4 right pleural reactive effusion or right lower lobe discoid atelectasis.

When the cystic duct is patency and the gallbladder is still well-concentrated, oral cholecystography can show the negative shadow of stones in the gallbladder with an accuracy of 95%.

If the cystic duct is unobstructed, intravenous cholecystography can show the negative shadow of the gallbladder.

The wall thickness of the gallbladder is visible on the CT image, and there are stones and bile deposits in the capsule. Oral gallbladder contrast agent CT scan can increase the resolution of the stone.

Differential diagnosis

1. Chronic gastritis: The main symptoms are upper abdominal bloating pain, hernia, loss of appetite and history of dyspepsia. Fiber gastroscopy is extremely important for the diagnosis of chronic gastritis. It can be found that gastric mucosal edema, congestion, mucous membrane color turns yellow or grayish yellow, mucosa atrophy. Hypertrophic gastritis can be seen as mucosal folds hypertrophy, or nodules and visible erosion and superficial ulcers.

2. Peptic ulcer: a history of ulcers, upper abdominal pain is related to regular diet, and gallstones and chronic cholecystitis often increase pain after eating, especially into high-fat foods. Ulcer disease often occurs in the spring and autumn, and gallstone chronic cholecystitis is more common than nighttime. Barium meal examination and fiber gastroscopy have obvious discriminating value.

3. Gastric neurosis: Although there is a long history of recurrent episodes, it has no obvious relationship with eating greasy, and is often closely related to mood swings. Often have neurological vomiting, each sudden vomiting after eating, generally no nausea, vomiting is not much and effortless, can eat after vomiting, does not affect appetite and food intake. The disease is often accompanied by systemic neurological symptoms, suggestive therapy can relieve symptoms, identification is not difficult.

4. Gastroptosis: This disease can have liver, kidney and other organs drooping. Abdominal discomfort is aggravated after meals. Symptoms are relieved when lying down. The standing position examination shows that the lower abdomen is full, while the upper abdomen is emptied. Sometimes the stomach type can be seen and there is a water sound. The barium meal examination can confirm the diagnosis.

5. Kidney drooping: There are often symptoms such as poor appetite, nausea and vomiting, and more common on the right side, but the right upper abdomen and lower back pain are aggravated when standing and walking, and colic may appear and radiate downward. Physical examination was palpated in the supine position, sitting position and standing position. If the right upper quadrant was found to be displaced due to the change of body position, it would be meaningful for differentiation. Lying and standing kidney X-ray and intravenous urography can help. For diagnosis.

6. Prolonged hepatitis and chronic hepatitis: This disease has a history of acute hepatitis, and there are symptoms such as chronic dyspepsia and right upper quadrant discomfort. There may be liver and liver dysfunction, and splenomegaly, spider mites and liver may occur in chronic hepatitis. Palm, B-ultrasound examination of the gallbladder function.

7. Chronic pancreatitis: often the sequela of acute pancreatitis, the upper abdominal pain is radiated to the left shoulder and back, X-ray plain film sometimes shows pancreatic calcification or pancreatic stones, fiber duodenoscopy and retrograde cholangiopancreatography for diagnosis Chronic pancreatitis has a certain value.

8. Gallbladder cancer: This disease can be combined with gallstones. The disease has a short history, rapid development of the disease, and rapid lymph node metastasis and direct invasion of nearby liver tissue, so persistent jaundice occurs. The right upper quadrant pain is persistent. When the symptoms are obvious, most patients can reach a hard mass under the right upper abdomen. B-ultrasound and CT examination can help diagnose.

9. Liver cancer: Primary liver cancer, such as the occurrence of right upper quadrant or upper abdominal pain, has been late, and often can be swollen with a nodular liver. B-ultrasound, radionuclide scanning and CT examination can be found in the liver with tumor images and radiation defects or density reduction areas, alpha-fetoprotein positive.

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