Medical experts talk about science | Q&A about gallstones

Cholelithiasis is a common and frequently occurring disease of the digestive system. Many people would ask, why are there stones in the gallbladder? Who is prone to gallstones? What are the symptoms of cholelithiasis? How can we detect it in time? How to deal with it? Let's hear what the experts have to say.

| Why are there stones in the gallbladder?

The cause of gallstones is very complex and is not yet clear. It is related to many factors, including environmental factors, genetic factors, and personal lifestyle. In short, any factor that affects the ratio of cholesterol to bile acid and phospholipid concentrations in the human body and causes bile stasis can lead to stone formation.

| Who is prone to gallstones?

Gallstones are mainly seen in adults, with a higher incidence in women than in men. The incidence increases with age after the age of 40. Female hormones, obesity, pregnancy, high-fat diet, long-term parenteral nutrition, hyperlipidemia, diabetes, cirrhosis, hemolytic anemia, family history of gallstones and other factors can cause gallstones. However, with the change of eating habits and regularity, especially the increase of skipping breakfast and high-fat diet habits among young people, the incidence of gallstones has a tendency to become younger.

| What symptoms can gallstones cause? How can we detect them in time?

The diagnosis of gallstones requires early identification, because most patients do not have any symptoms. Routine physical examinations have become an important means of identifying gallstones. Some patients often experience dull pain in the upper abdomen after a full meal or greasy food, or feel bloating, belching, etc., which are often considered to be stomach problems. Therefore, it is important to pay attention to the difference between gallstones and stomach problems, and not to mistake gallstones for "stomach problems." The clinical history of typical biliary colic is an important basis for diagnosing the disease. Abdominal ultrasound can confirm the diagnosis, and CT and magnetic resonance imaging can be used when necessary.

| How to prevent gallstones?

Dietary structure has a very important impact on the occurrence of gallstones. Regular consumption of high-fiber foods can effectively reduce the occurrence of gallstones. Eating less greasy, fried, or roasted foods, and eating more nuts, vegetables, and fruits can also reduce the formation of gallstones. In addition, regular three meals a day is an important way to prevent gallstones, especially breakfast, because the bile in the gallbladder is significantly concentrated in the morning, and excreting this bile after eating is very important for preventing the formation of stones.

| What effects may gallstones have on the human body?

Most patients with gallstones may be asymptomatic, which is called asymptomatic gallstones. However, some gallstones usually cause acute or chronic cholecystitis. Repeated inflammation may affect work and life. If gallbladder inflammation continues to develop, gallbladder wall necrosis and perforation, peritonitis, and severe cases may be life-threatening. Studies have shown that 70% of gallbladder cancer patients are related to repeated cholecystitis caused by gallstones.

| Do all patients with gallstones need to have their gallbladder removed?

For patients with asymptomatic gallstones, the consensus in Europe and the United States is that non-surgical observation and treatment are the main approach. No internal or surgical intervention is required unless there is calcification of the gallbladder wall or space-occupying lesions. Cholecystectomy is generally not recommended, and gallbladder-preserving stone removal surgery is not performed. Due to the limitations of medical conditions and cultural differences, there is no consensus on the treatment of such patients in China. The author's team believes that for asymptomatic patients who can undergo regular physical examinations, have no obvious symptoms, and have a functional gallbladder, we are not positive about surgical treatment.

Surgery is recommended for patients who meet the following conditions:

(1) Patients with recurrent pain and discomfort in the right upper abdomen.

(2) Obese women over 40 years old with a long history of gallstones.

(3) Elderly patients and those with multiple underlying diseases.

(4) Patients suspected of having a high number of gallstones with a diameter ≥2-3 cm, gallbladder atrophy, gallbladder wall calcification or porcelain gallbladder, or gallbladder polyps ≥1 cm due to physical examination are suspected of having a risk of malignancy.

The preferred surgical method is laparoscopic cholecystectomy, which is equally effective as open cholecystectomy and has the advantages of quick recovery, less trauma, less pain, and less visible scars. Currently, cholecystectomy is still the world-recognized "gold standard" for the treatment of gallstones.

| What are the consequences of “losing courage”?

The secretion of bile comes from the liver, and the gallbladder cannot produce bile. Its main function is to concentrate and store bile. Therefore, the secretion of bile is not affected after the removal of the gallbladder. A low-fat diet is required in the short term after cholecystectomy. Generally, after 2-3 months, the bile duct will compensatorily expand and play a partial role of the gallbladder, and you can gradually transition to a normal diet. Some patients experience symptoms of digestive dysfunction such as abdominal distension and diarrhea after surgery. This may be related to the change in the bile excretion pattern caused by the surgery. Symptomatic treatment with drugs such as supplementation of digestive enzymes, promotion of bile excretion, and intestinal calcium ion antagonists can generally improve the condition. In general, the impact on life after cholecystectomy is small.

| Does gallbladder removal solve the gallstone problem once and for all?

After cholecystectomy, stones may still form in other parts of the biliary system, including the intrahepatic and extrahepatic bile ducts. This is because the causes of intrahepatic and extrahepatic bile duct stones are different from those of gallbladder stones, such as bile pigment metabolism disorders, bile duct anatomical abnormalities, and retrograde bile duct infection. Therefore, a small number of people may still develop intrahepatic and extrahepatic bile duct stones after cholecystectomy.

| Are extrahepatic bile duct stones more complicated than intrahepatic bile duct stones? How to treat them?

Compared with gallbladder stones, extrahepatic and intrahepatic bile duct stones are more complicated. Some people use the biliary tree to metaphorically describe the biliary system. The extrahepatic bile duct is the trunk, and the intrahepatic bile duct is the branches. Stones may appear in these locations, which will further affect the outflow of bile. If the stones block the trunk or part of the branches, the bile cannot flow out and the patient will experience symptoms. Therefore, the stones should be resolved as soon as possible.

Specific methods include endoscopic retrograde cholangiopancreatography (ERCP) + endoscopic papillary incision (EST) stone removal and surgery, because combined with choledochoscopy during or after surgery, stones are easily removed. Specific and more in-depth questions require detailed explanations from doctors based on each condition.

Author | Zhang Xuewen

Hepatobiliary and pancreatic surgery expert at the General Surgery Center of the Second Hospital of Jilin University, Tang Aoqing Scholar, Professor of Jilin University, Doctor of Medicine, Chief Physician, and Doctoral Supervisor. He has been engaged in general surgery clinical work for more than 30 years. He is good at complex surgical treatment of hepatobiliary and pancreatic malignant tumors and retroperitoneal tumors, and the treatment of difficult and critical cases of hepatobiliary and pancreatic. He has conducted systematic research on hemodynamic changes of cirrhosis and portal hypertension, and perioperative evaluation of liver reserve function, and has successively developed a number of new technologies and treatments for hepatobiliary and pancreatic surgical diseases.

He is currently a member of the National Committee of the Surgery Branch of the Chinese Medical Association, deputy leader of the Surgery Group of the Surgery Branch of the Chinese Medical Association, vice president of the Surgery Branch of the Chinese Medical Association, vice chairman of the Liver Cancer Professional Committee of the Chinese Medical Association, vice chairman of the Tumor Surgery Branch of the Surgery Branch of the Chinese Medical Association, vice chairman of the General Surgery Committee of the Professional Committee of the Chinese Research Hospital Association, member of the Ministry of Education's College Clinical Medicine Teaching Steering Committee, director of the first batch of Chinese Medical Association Laparoscopic Surgery Training Base, consulting expert of the Fifth Central Health Committee, chairman of the General Surgery Branch of the Jilin Provincial Medical Association, member of the First Jilin Provincial Professional Degree Graduate Education Steering Committee, etc. He also serves as an editorial board member of textbooks such as "Surgery (9th Edition)" and "General Surgery (2nd Edition)" published by the People's Medical Publishing House, and an editorial board member of magazines such as "American Annals of Surgery (Chinese Edition)", "Chinese Journal of Surgery", "Chinese Journal of Digestive Surgery", "Chinese Journal of Practical Surgery", and deputy editor-in-chief of magazines such as "International Journal of Surgery", "Electronic Journal of Liver Cancer", and "Chinese Journal of Gerontology".

He has won honorary titles such as "Expert with Outstanding Contributions from Jilin Provincial Government", "Young and Middle-aged Talent with Outstanding Contributions from Jilin Provincial Health Department", "Undergraduate Teaching Outstanding Teacher Award of Jilin Higher Education Institutions", "Contribution Award for Medical Education of Jilin University", "Model Teacher of Jilin University", "Bethune Outstanding Teacher of Jilin University", "Bethune Outstanding Doctor of Jilin University", and "Model of 'Three Educations' of Jilin University". He has won the second prize of the Second National Outstanding Papers of Young and Middle-aged General Surgery, 6 Jilin Provincial Science and Technology Progress Awards (including 1 first prize, 2 second prizes, and 3 third prizes), 9 Jilin University Medical Achievement Awards, and 1 Changchun Science and Technology Progress Award. He has published more than 100 academic papers in SCI and Chinese series of journals, and edited and co-edited 6 books.

| Discipline Introduction

The Department of Hepatobiliary and Pancreatic Surgery of the Second Hospital of Jilin University was established in February 2013. As an important part of the General Surgery Department of the Second Hospital of Jilin University, a national key specialty construction project, it has now become one of the largest hepatobiliary and pancreatic surgery diagnosis and treatment centers in Jilin Province. The department currently has 24 doctors, including 6 professors, 6 associate professors, and 2 doctoral supervisors. 80% of the doctors have doctoral degrees; there are 33 nurses, including 7 specialist nurses and 11 head nurses or above.

The department is the vice-chairman unit of the Chinese Medical Association's Surgery Branch and the Chinese Medical Association's Liver Cancer Professional Committee, the vice-leader unit of the Chinese Medical Association's Surgery Branch's Surgery Group, the chairman unit of the Jilin Provincial Medical Association's General Surgery Branch, a national-level general surgery clinical specialty training base, and a dominant discipline of the Second Hospital of Jilin University. At present, it has undertaken more than 30 national and provincial and ministerial projects, received nearly 10 million yuan in funding, won more than 10 provincial, municipal, and school scientific research and medical awards, and published more than 20 SCI and core journal articles each year.