Gallstone disease is a painful condition in which, due to abnormal metabolic functions in the gallbladder and its tubules, the calcification of enzyme substances occurs. The disease is scientifically called cholelithiasis.
Essence of cholelithiasis
The gallbladder is an organ containing bile produced by the liver cells. Gallstones can be seen in the organ, its ways, the liver, its duct. Formations vary in composition, volume and appearance. The forerunner of cholelithiasis is cholecystitis without stones - aggravation or sluggish inflammation in the organ. In such a case, the pebbles cannot be found in the gallbladder on the ultrasound. There are episodes when stone structures began to form, but due to their small size they are not visible even on X-rays - X-ray negative stones.
Cholesterol crystals act as a building material for calculus, less often - calcium pigment-lime salts.
The disease provoked by stony formations in the gallbladder is an extremely common phenomenon. The pathogenesis of the disease is caused by improper diet, eating an excess of food of animal origin.
Nursing process for cholecystitis
Nursing process for cholelithiasis includes: the study of etiology and provoking factors, the establishment of the clinical picture, diagnosis, treatment and prevention. The main stages of primary care, the tactics of the nurse's behavior in the care of patients suffering from the disease are distinguished.
Symptoms and causation of stones
How to find out about the presence of gallstones? Often the disease goes unnoticed, the clinic of gallstone disease is missing for decades. The manifestation of symptoms due to the number of formations, volumes and location.
Symptoms of gallstone disease:
- Colic in the liver and under the ribs on the right.
- Sickness, passing into vomiting.
- Bitterness in the mouth, multiple air outlet from the mouth.
- There are constipation, diarrhea, causing diarrhea, the stomach swells, the stool becomes colorless, almost white.
- Feeling weak.
- The body temperature rises.
- Botkin's disease develops.
Causes of the first signs
Pain due to stones occurs due to spasm of muscle fibers, irritation of the cavity of the gallbladder and channels, or overstretching of the walls of the body due to excess bile.
Severe pain is accompanied by the promotion of stones through the tubules, causing blockage. When the duct completely overlaps, the liver increases, there is a aching pain in the region of the ribs, yellowing of the skin and eyeballs, the stool loses its color, the temperature rises, the person sweats, he fevers, and convulsive seizures occur.
Cases when the pebble leaves independently are described, attacks stop. If the calculus is large or in the gallbladder accumulates a lot of small stones, urgent surgical treatment of gallstone disease is necessary.
The disease is accompanied by vomiting reflexes with bile patches. It does not become easier after vomiting, the reaction occurs at the reflex level and becomes a consequence of irritation in the duodenum.
An elevated temperature indicates an infectious disease of the gall bladder, lack of appetite and constant fatigue are considered obvious companions.
The bile of a healthy person is liquid, capable of forming pebbles. Risk factors affecting the gallstone process:
- An abundance of cholesterol in the bile fluid.
- Obstruction of bile discharge, congestion in the bladder.
- Penetration of the causative agent of infections in the gallbladder.
The etiology of gallstone disease is:
- Eating too much cholesterol.
- Poor liver function, accompanied by underproduction of bile acids.
- The long-term use of birth control pills.
- The presence of certain diseases.
There are a lot of reasons for which the outflow and stagnation of bile are disturbed. The main factors are: poor reduction in the biliary tract, flatulence, surgery in the gastrointestinal tract, low physical activity of a person, pregnancy, abnormal diet after childbirth, exhaustion of the body by hunger, a sharp weight loss. Stagnation may be caused by obstruction of the ducts as a result of adhesions, puffiness, contraction or bending of the bladder, the occurrence of tumors.
Staging of gallstone disease
There are three stages of gallstone disease:
- The first, which disrupts the balance of the constituent parts of bile produced by the liver, in the direction of the predominance of cholesterol.
- The second stage involves the formation of the actual stones on the background of an excess of cholesterol and irregular circulation of bile.
- The third is the formation of complications against the background of the progression of gallstone disease.
Types of education
In medical practice, there are two types of stone formation: primary and secondary. The first case involves the formation of stones in the bile ducts with a normal structure due to a violation of the composition of the bile fluid, when the formations do not appear for a long time. In the second case, pebbles are formed when bile discharge is difficult, the cause of which is cholestasis, increased pressure in the bile fluid, and slagging of the bile ducts.
Depending on the structure, the stone in the gallbladder is homogeneous or complex, consisting of a nucleolus (bilirubin), a calf and a peel. The composition of the homogeneous include: lumps of mucus, cholesterol, foreign objects.
Based on the chemical composition, emit: cholesterol, limestone, pigment and multi-component. In practice, predominantly complex, with a greater proportion of cholesterol.
The structure of the stones are divided into: crystalline or layered, hardened or waxy.
The volume of stones fluctuate at different scales from a millimeter, at which a person is able to live, having no idea about the existence of inclusions, to centimeters. Facts are known when a huge stone was found in a bubble, stretching an organ and occupying space. Stones up to 1 cm are considered small, medium - 1-2 cm, large - large stones. More often find stones from 0,1 to 5 cm.
The danger of gallstone disease is complications. These include: exacerbated cholecystitis, the overlapping of the pathways leading to bile fluid, infection, violation of the integrity of the bile, the penetration of petrified bile into the intestine with the development of obstruction, the development of tumors.
Diagnosis of the disease
Ultrasonic and endoscopic monitoring is carried out to clarify the diagnosis of cholelithiasis. Large stones are determined by palpation. The quantity, size and location of the stones, the condition of the bubble are determined by the method of ultrasound.
If it is difficult to establish an accurate diagnosis, they use the method of oral cholecystography, which includes examining the state of X-rays after ingesting a specific contrast agent, as well as X-ray exam, supplemented with endoscopy.
The methodology of healing, providing the opportunity to save the diseased bladder and tubules, to clean it, include:
- Therapy of dissolution of stones with drugs.
- Medical treatment, allowing to remove the stones by ultrasonic or laser crushing.
- The ability to remove calculus by dropper method.
Meaning of the method: the slagged bladder is designed to cleanse drugs that can reduce the amount of bile cholesterol and increase the content of bile acids.
Such treatment is prescribed when cholesterol is an integral part of the stones. The formations are small, the tubules are passable and are able to contract normally. The method is contraindicated in diseases of the intestines and kidneys.
The treatment is long, for about two years. The dosage is calculated individually for the patient. Medication is monitored by ultrasound monitoring. It is proposed to lead a correct lifestyle, to conduct prevention of neoplasm of stones.
A huge minus of the method recognized the resumption of the disease at the end of the course. Stopping the flow of medication into the body can increase a certain level of cholesterol in the bile. To stop the use of the drug is undesirable, you need a constant reception of the minimum dose.
The stones in the gallbladder are fought by crushing with shock oscillations. Ultrasonic vibrations crush the stones into pieces, which then pass through the channels into the duodenum.
In practical terms, the method is supplemented first: the ability to remove crushed parts by taking drugs is determined. The laser crushing method works in the same way.
The method is shown to those who have found up to four large stones without lime impurities or the only one large. Often cost 1-7 procedures. Therapy is prohibited for poor blood coagulation, diseases of the esophagus.
Causes of gallstone disease and its asymptomatic course
If gallstone disease does not bother, doctors do not recommend removing gallbladder. The main reasons due to which stones are formed in the cavity of an organ include:
- often eating foods with an increased amount of animal fats in their composition,
- hormonal imbalance
- lack of exercise
- disorders of fat metabolism, often this is accompanied by a set of extra pounds,
- inflammatory processes in the cavity of the reservoir,
- pathological processes in the tissues of the liver,
- period of carrying a child,
- frequent fasting
- genetic predisposition
- development of diabetes
- diseases of the small intestine.
There are also provoking factors: damage by helminths, alcoholic cirrhosis of the liver, infectious processes in the bile ducts, advanced age.
Asymptomatic disease can continue for many years. Often a person does not even suspect the presence of stones in his gallbladder, they are discovered by chance, during the passage of an ultrasound examination of the abdominal cavity organs. In this case, the patient is recommended constant medical supervision, monitoring the development of the disease, can also be prescribed drug therapy, which aims to crush small deposits.
Upon detection of large stones, the occurrence of severe painful attacks, high fever and various complications, they are used to fight stones with operational methods.
It is possible to clean the bile from petrified bile fluid using laparoscopy or abdominal surgery. The most common method of surgical treatment for many years consists in the complete elimination of the affected organ. It is forbidden to use laparoscopy with severe obesity, the huge size of the stones, operations performed in the stomach earlier, with suppuration on the bladder, heart and respiratory diseases, pregnancy.
Consequences of the elimination of the bubble: there is pain in the place of removal, a bitter taste in the mouth, the possibility of subsequent infection with Botkin's disease.
Prevention of gallstone disease
In order to prevent the disease, it will be necessary: to eat moderately, food must contain less fat. Sport is recommended. It is necessary to undergo periodic examination, if necessary, to reduce the amount of cholesterol produced by the liver, to affect the reproduction of bile acids. Essentiale Forte is prescribed.
Bilious colic. This is a severe pain in the upper abdomen. The pain is usually localized on the right side, under the ribs. This is due to the fact that the stone is stuck in the duct of the gallbladder. The pain is relieved if the stone is pushed through the bile duct (usually into the intestine), or if it returns to the gallbladder.
The pain from biliary colic can last from several minutes to several hours. There is pain from time to time, especially after ingestion of fatty foods, when the gallbladder contracts most.
Inflammation of the gallbladder. This disease is called cholecystitis. Symptoms usually develop quickly and include abdominal pain, increased body temperature, and general unwellness.
Jaundice. This is a rather rare complication due to gallstones. Jaundice may occur on the background of the delay stone in the bile ducts. In this case, the bile can not pass into the intestines, and penetrates the bloodstream. (Note: There are many other causes of jaundice other than gallstones.)
Pancreatitis. This is an inflammation of the pancreas. The pancreas also produces the enzymes necessary to digest food. Pancreatic enzymes and bile ducts are combined before they enter the duodenum. If the gallstone is stuck in the common duct, pancreatitis may develop.
Sometimes stones in the gallbladder provoke the development of severe infections of the bile ducts (cholangitis) and cause some diseases of the intestines.
Treatment of gallstone disease
As soon as gallstones begin to give symptoms, surgical treatment is usually prescribed. The doctor may prescribe you antispasmodics (no-spa), painkillers and antibiotics (amoxiclav, panclave, etc.), in case of an infection of the gallbladder. After the operation is performed, usually in a week.
If the patient refuses the operation, treatment with ursodeoxycholic acid (Ursosan) and other medications to remove stones from the gall (urolesan, etc.) is used. Under the influence of these drugs, gallstones dissolve. However, treatment is not always successful and takes time. Shock-wave cholelithotripsy is also used for crushing gallstones. Physical activity, diet, phytotherapy and physiotherapy are prescribed as additional measures.
Surgery to remove the gallbladder
The patient may be recommended various methods of gallbladder removal, depending on the location of the stones, their size and other factors.
- Laparoscopy (laparoscopic cholecystectomy) is currently the most common way to remove the gallbladder. The operation is performed using a special telescope (laparascope), which is inserted into the abdominal cavity through a small incision. This allows the surgeon to see the gallbladder. Instruments for surgery are inserted through other small incisions. However, laparascopy is not suitable for all patients.
- Some people with gallstones need traditional lung surgery to remove the gallbladder. Such an operation is called cholecystectomy.
- If the stone gets stuck in the bile ducts, other surgical procedures can be performed.
After removal of the gallbladder
The process of digesting food can be carried out without the gall bladder. When the gallbladder is removed, bile from the liver goes directly into the intestine.
If the patient did not follow a strict diet before the surgery, it will not be necessary even after the gallstones are removed.The patient can eat regular food, should only limit the use of animal fats such as lard, bacon, roast lamb. Patients who before the operation were forced to adhere to a strict diet will be able to gradually expand their diet.
After removal of the gall, about half of the patients occasionally notice moderate abdominal pain or bloating. Some people notice an increase in stool frequency. It looks like mild diarrhea. You can fight diarrhea with antidiarrheal drugs.
Gallstone disease refers to both therapeutic and surgical pathology. The very fact of having stones is not dangerous to human life and health. The danger is a possible complication that occurs during the interaction of stones and biliary organs.
The most common complication of the disease is the occurrence of biliary colic. In this case, the stone from the gallbladder enters the common bile duct (choledoch).
When the size of the stone is smaller than the diameter of the duct, it passes through it into the small intestine. However, when the stone comes into contact with the wall of the choledochus, spasmodic painful sensations occur. As a rule, colic passes within half an hour.
If the size of the stone exceeds the diameter of the common bile duct, it is blocked with a stone. As a result, pressure rises and acute inflammation of the gallbladder is formed. This complication requires immediate surgical intervention.
The main reason for the formation of gallstones is the stagnation of bile. The combination of this condition with the presence of stones in the bladder leads to the formation of a chronic inflammatory process. Chronic cholecystitis causes a decrease in the activity of the immune system. As a result, a person becomes more susceptible to the occurrence of various viral and bacterial infections.
The presence of chronic inflammation is especially unpleasant in women who want to get pregnant. The inflammatory process can affect both the possibility of becoming pregnant, and lead to complications during the period of carrying a baby. Chronic cholecystitis can cause the occurrence of fetal pathology of the child or complicate the course of pregnancy and childbirth in the mother.
Appeal to the surgeon
It is worth going to a consultation with a surgeon immediately after visiting a doctor for ultrasound diagnostics. It is necessary to take pictures with you where the bubble and its contents are visualized. Even one stone in the gallbladder can cause acute surgical complications. It is the surgeon who can estimate the size of the stones and clarify whether an operation is needed to remove the organ in a particular case.
There are several indications for surgery:
- pronounced clinical picture of gallstone disease,
- progressive colic,
- the presence of large stones in the bubble,
- the presence of small stones, occupying 50% or more of the organ cavity,
- lack of adequate contraction of the gallbladder,
- the presence of inflammatory changes in the cystic tissue,
- severe hypertension in the bile ducts of the liver,
- the presence of a stone near the entrance to the common bile duct,
- inflammation of the gallbladder.
The latter option provides not only the presence of stones in the gallbladder or the common bile duct, but also an increase in pressure in the bile ducts, as well as inflammation of the entire organ. In this case, acute cholecystitis develops. This situation requires immediate surgical intervention and removal of the organ.
Symptoms of acute cholecystitis with cholelithiasis, which require immediate surgical intervention:
- acute cutting or spasmodic pain in the right hypochondrium, which lasts more than an hour,
- dull pain in the right hypochondrium, which is observed for more than two hours,
- pain is not relieved by antispasmodic drugs,
- spreading pain from right hypochondrium throughout the abdomen,
- body temperature rises above 37˚С,
- appearance of vomiting (once or more).
The development of acute cholecystitis on the background of gallstone disease requires the removal of the gallbladder as a matter of urgency. There is no additional time to prepare the body for surgery.
In the absence of renal colic and acute cholecystitis, doctors recommend resorting to a planned surgery to remove the gall bladder. Such surgery is considered less traumatic for the body and makes it possible to conduct long-term preoperative preparation.
When you can do without surgery
Not always the presence of stones requires surgical intervention. There are options when you can get rid of stones without surgery:
- Stones of small size - their diameter is less than the diameter of the common bile duct.
- Single large stones (one or two) that can be crushed by ultrasound.
In such cases, choleretic drugs are prescribed and stones independently leave the gallbladder in a natural way and are removed from the body along with feces. At the same time occasional colic may develop, but only if the stone comes into contact with the wall of the common bile duct. As a rule, such colic quickly passes, and discomfort sensations are eliminated by antispasmodic drugs.
It is worth noting that even with the presence of small stones (or detailed large stones), the main problem does not disappear - the stagnation of bile and the ability of the gallbladder to form stones. Therefore, even if you remove all the small stones with choleretic drugs, they can again be formed in the bladder. The only way to permanently get rid of this problem is to remove the gallbladder.
From the moment of the appearance of stones in the gall bladder and until the emergence of the need for surgical intervention may take years. And all this time, man has to live with stones in the gall bladder.
There are several options for the course of gallstone disease:
- with manifestations of colic,
- with manifestations of chronic cholecystitis.
Asymptomatic disease is considered the most favorable. It eliminates the presence of colic and the occurrence of its complications. However, even with an asymptomatic course, the formation of complications from the liver, pancreas, small intestine is possible.
The presence of colic indicates the release of stone from the gallbladder into the common bile duct. This condition occurs when the diameter of the stone exceeds the dimensions of the duct and its lumen is blocked. This condition leads to a violation of the outflow of bile, increased pressure in the duct and the formation of acute cholecystitis. It also complicates surgery - in addition to removing the gallbladder, you also need to get a stone from the duct.
Another option is the formation of chronic cholecystitis. This disease develops as a result of stretching of the walls of the body with stones, stagnation of bile. This creates favorable conditions for the reproduction of microorganisms. Chronic inflammation leads to the loss of its main function by the body - the accumulation of bile and its batch movement into the small intestine.
Another unpleasant complication of gallstone disease is an increase in pressure in the bile ducts of the liver. The presence of calculus always stretches the bladder wall as a result of which the pressure in the biliary vessels of the liver, which is directly connected with this organ, rises. Within six months after the formation of stones, the development of hypertension in the bile ducts is observed. This leads to impaired liver cell function. In cases of chronic disease, noninfectious hepatitis is formed - inflammation followed by destruction of liver cells. If you do not prevent the development of this condition, fibrosis and cirrhosis can form.
A rather rare, but the most unpleasant complication of gallstone disease is the development of cancer of the gallbladder and liver. Such situations can occur with chronic course of the disease, the presence of prolonged inflammation and stagnation of bile, as well as in the absence of treatment. Gallbladder cancer can go to the liver very quickly and it will be much more difficult to treat it.
The role of therapeutic interventions
The main danger in the presence of cholelithiasis is the development of acute cholecystitis and the emergence of the need for urgent surgical intervention. However, there are other complications that can significantly degrade the quality of human life. The main thing is a violation of digestion.
Bile is needed in the body for emulsification (proper breakdown) of fats in the small intestine. Normally, when food enters the small intestine, the gallbladder releases a sufficient portion of bile, as a result of which pancreatic enzymes are activated and normal fat absorption occurs. In the case of gallstone disease, the gallbladder continues to accumulate bile. However, the presence of stones does not give him a normal cut. An insufficient amount of bile enters the small intestine. Pancreatic enzymes remain inactive and fat splitting does not occur.
This situation leads to insufficient absorption of beneficial polyunsaturated fatty acids. These substances are mandatory structural elements of the cell wall. Their insufficient content in the body leads to disruption of cell regeneration (skin, stomach). The external manifestations of this complication are quite easy to notice:
- dry skin,
- taste disorders
- brittle hair,
- problems with nails
- exacerbation of chronic diseases.
An insufficient amount of bile also leads to an excessive secretion of pancreatic enzymes, resulting in a depleted function of this organ. You can notice problems with the pancreas only in the phase of lack of enzymes:
- the presence of constipation (absence of defecation for more than three days),
- the appearance of diarrhea, an increase in the act of defecation more than three times a day,
- alternating constipation and diarrhea,
- the appearance of a feeling of heaviness in the epigastric region,
- the occurrence of low-intensity dull pain in the epigastric region,
- the occurrence of surrounding dull pain on the left.
How to prevent the development of complications
An experienced doctor will always determine the presence of a particular complication. However, it is much more important to prevent the development of such situations. There are several simple recommendations, the implementation of which will help to significantly reduce the risk of dangerous manifestations of gallstone disease:
- Permanent diet. Even a single violation of the recommended diet can lead to the development of colic or acute cholecystitis.
- Clear reception of prescribed drugs. The lack of taking prescribed drugs leads to an increased risk of developing complications of cholelithiasis. Contribute to the occurrence of complications can also self-replacement drugs. It should be remembered that in the absence of any drug in the pharmacy, only the attending physician, and not the pharmacist, can allow its replacement.
- Ultrasound of the gallbladder and liver at least once every six months.
- Consultation surgeon every six months.
- Consultation by a therapist or gastroenterologist every three months.
- Surrender analysis of feces every six months to determine the function of the pancreas.
- To give up smoking. Nicotine is not easily harmful to the whole body - it contributes to the thickening of bile and the formation of gallstones.
Compliance with these recommendations will help to significantly reduce the risk of complications of cholelithiasis and slow down the process of the formation of new stones in the gall bladder.
What are dangerous stones in the gallbladder, if they do not bother?
Such stones may be very small, and can grow up to five centimeters in diameter. With the appearance of pain on the right and other disturbing symptoms should not hesitate to contact the doctor. Many people successfully cope with the problem even at the asymptomatic stage of their development.
Subsequently, this problem is fraught with dangerous complications for the body, including:
- Development of biliary colic attack. It is characterized by intense pains on the right. An attack was provoked by sticking a stone in the canal. When it comes out or comes back into the gall cavity, the pain subsides. This condition can last from several minutes to days.
- Inflammatory process in the gallbladder. The clinical picture is pronounced - body temperature indices increase, pain appears, vomiting occurs, a person feels very weak.
- Yellowness of the skin. This complication occurs due to stagnation of bile.
- Pancreatitis is characterized by an acute or chronic inflammatory process in the tissues of the pancreas.
- The development of serious infectious processes in the intestinal tract.
- Severe infectious process in the channels.
- Diseases of the intestinal tract.
It is important not to allow this disease to flow. Continuous monitoring and adherence to medical recommendations will help prevent complications.
Do I need to remove the gallbladder if there are no symptoms
Do I need to remove the gallbladder if there are stones in it? If the organ can be cleaned, should it be removed? Doctors agree that if the stones in the gallbladder do not cause anxiety and do not increase in size, it is better not to touch them. It is important to have an operation if the stone has already begun to grow or has moved. For a long time such deposits may not disturb. No pain and other symptoms. In the presence of stones it is necessary to take into account the opinion of doctors. Usually, if there are no warning signs of cholecystitis, there is no indication for removal of the organ.
In this case, conservative measures are taken to prevent the further development of the disease or for completeabout getting rid of it. The main thing - to follow a diet: eliminate from the diet fatty, fried, spicy and smoked food. You can not take any choleretic drugs, especially on their own, without the appointment of a doctor. If the stone has a small size, special medicines are prescribed for its dissolution and removal.
Also, with small sizes of stones, you can try to crush them with a shock wave. You can live with stones, only to control their further development and to take drugs prescribed by the attending specialist.
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Indications and contraindications for gallbladder removal
According to many doctors, JCB is treated radically, if there are indications. Always remove the gallbladder in the presence of polyps, organ cholesterase, with calculous cholecystitis. The organ is always removed if the bile ducts are stoned. In the case of developing biliary colic. Contraindications include:
- The development of diabetes.
- Severe damage to the heart.
- Periods of carrying a child.
- Acute inflammatory process in the pancreas.
- Mechanical jaundice.
- Suspected tumor development.
- Pathology in the blood system.
Stones up to 2 cm are treated with the help of conservative therapy.
Why does the disease appear
The reasons for the formation of gallstones are a violation of the balance of substances contained in bile, their stagnation. Causes of stagnation of bile in the body:
- The liver is unable to process large amounts of animal fat.
- After suffering liver disease, for example, viral hepatitis, the body is not able to function in full force.
- Through a general metabolic disorder of fats due to diseases: diabetes mellitus, thyroid disease.
- Women during pregnancy or menopause are in the “risk group”, in such a state the hormonal level changes.
- With a sharp drop in red blood cells.
- In case of hereditary tendency to the specified pathology.
Accelerates the appearance of stagnation:
- Adhesions, anatomical anomalies that prevent the flow of bile.
- Lack or lack of physical activity.
- Squeezing of the biliary tract due to pregnancy.
- Long fasting, various injuries of the spinal cord.
- Parasitic diseases, inflammation of the digestive tract.
- Alcohol and chronic diseases.
Stones formed under the influence of cholesterol
The most typical cases are when cholesterol stones are formed under the action of cholesterol. Unfortunately, the people of the world follow the western type of food, which is distinguished by an abundance of cholesterol in food.
The formation of stones in the gall bladder occurs through the stagnation of bile, rapid weight loss, a large number of operations.
Stages of development of the disease
Modern classification divides the disease into four stages:
- Dokamena, the initial stage in which the concentration of salt dissolved in bile changes.
- Hidden, no symptoms. Changes in the composition of bile are already detected.
- Clinical manifestation. Symptoms indicate the presence of stones.
- Complications resulting in concomitant diseases.
How to diagnose a disease
The initial and latent stages of the disease are more often detected along with other diseases. For example, gallstone disease is determined by a blood test. With the help of biochemical studies recognize the concentration of substances contained in the composition of bile.
A high concentration of salt in bile helps to establish duodenal intubation. With the help of X-rays reveal the change in the volume of the gallbladder, seal the walls, the presence of stones.
Using ultrasound to determine the mechanical damage, the presence of stones, formed as a result of obstruction of bile.
There are other ways to establish the diagnosis, costly compared to the above, are appointed in extreme cases.
When the disease manifests itself
The disease manifests itself with an increase in the size of the stones, which during movement violate the patency of bile, damage the walls of the organ. The situation is aggravated by the consumption of fatty foods, alcohol. Intensive exercise can cause exacerbation of gallstone disease. Sometimes an attack occurs through vibrations when traveling by rail.
What are the symptoms of having gallstones?
Symptoms can occur unexpectedly:
- Pain is repeated systematically, felt in the right hypochondrium. Pain impulses reach the right scapula.
- Pains are accompanied by nausea and vomiting. Vomit becomes yellow.
- Appears yellow skin.
- Urine becomes dark, feces light.
- The temperature changes, with an increase in intoxication can rise to 38 degrees.
- Yellowish formations appear on the skin and tongue.
Pain in stones in the gallbladder often appear after drinking alcohol and fatty foods. Sometimes triggered by stress, weight lifting. Treatment of gallstone disease in such a case is reduced to the use of antispasmodics.
If after four hours the pain does not subside, this indicates a deterioration of the condition. Condition assessed by the attending physician.
As a result of bile entering the stomach, the patient feels bitter in the mouth. There is flatulence or constipation. The chair gets an unpleasant smell. Patients do not tolerate milk and dairy products.
In the third stage, pain in cholelithiasis sometimes affects the region of the heart. Often appear in the joints. In this case, the discomfort disappears immediately after the stones are removed. The duration of the attacks increases, and neurotic syndrome appears on the background of pain.
These symptoms of stones in the gall bladder indicate the need to think about treatment. Self-removing stones is life-threatening. An exceptionally competent doctor is able to accurately determine the diagnosis, prescribe a course of treatment.
Signs of gallstone disease are characterized by a high percentage of functional disorders. Such formations often contribute to the inflammation of neighboring organs. Stones injure the walls of the bladder and close the bile ducts.
In the worst case, stones prevent the flow of bile, often leading to serious health problems. For example, inflammation of the biliary tract causes biliary cirrhosis. The disease is not treated and often leads to death. In the case of compliance with doctor's prescriptions, survival projections are quite high.
How to treat a disease
Symptoms, treatment, and diet depend directly on the gallstones stage. While the stones are not felt, medicines are prescribed that can affect the composition of bile and help the liver. If discomfort occurs in the right hypochondrium, treatment of cholelithiasis is prescribed, which prevents the occurrence of complications.
Preventing another attack, the patient should follow the instructions of the doctor. Difficulties with digestion require strict adherence to the diet. We'll have to be strictly limited to fried, salted, spicy, sour. Alcohol and carbonated drinks are especially dangerous in this condition. It is better to refuse confectionery with cream.
Give advantages to steamed dishes, cereals, vegetables and dairy products. Of the drinks are useful in the diagnosis of herbal teas are considered, the broth from the hips.
Medications to avoid seizures:
- In order to reduce pain at stones, experts prescribe antispasmodics: atropine, no-shpa.
- Nausea and intoxication will remove antibiotics.
The patient must clearly understand that it is possible to completely get rid of the stones exclusively by surgery. With increasing sizes, the effectiveness of conservative treatment begins to tend to zero.
How to carry out surgery to remove stones
The operation is performed using endoscopic devices. In some cases, there are serious complications, for example, bladder empyema, peritonitis. Fistulas sometimes form between the bile duct and the intestines.
During the operation, the gallbladder is often removed along with the stones. There are several methods of surgical intervention:
- the classic way is to remove the bubble
- laparoscopic cholecystolithotomy, the organ remains, only stones are removed.
How to avoid relapse during stone formation
In order to avoid relapses, it will be necessary to follow the instructions of the doctor for several months, to avoid the use of drugs prohibited by the doctor. During treatment, you will have to reduce body weight due to the rejection of products containing excess cholesterol. In this state, it is extremely important to avoid starvation diets and body cleansing.
Protect yourself from the appearance of gallstones with coffee. A person who consumes more than four cups of a drink per day is less likely to get gallstone disease.
Caffeine has a good effect on the gallbladder, stimulating the contraction. But coffee will help only in the absence of stones. In the presence of formations it is better to switch to herbal tea.
A certain “risk group” is described, which includes patients who are more susceptible to the formation of stones: overweight people, women who gave birth, age patients.
A similar pathology may occur in young people leading a sedentary lifestyle. Modern nutrition system consisting of products stuffed with cholesterol, exacerbates the statistics. As a result of improper metabolism in the body remains an excess of substance, forming cholesterol stones.
The causes of the disease are different. All of them, regardless of origin, adversely affect the state of the gallbladder and other organs. The disease does not spare people. Patients should know that it is easier to prevent the disease than to get rid of, it is recommended to take care of health.
Bilirubin poisoning is already able to cause a lot of trouble. Complications of cholelithiasis after surgery are detected. So that readers can understand the extent of the pathology, we note that today surgeons are more often involved in removing the gallbladder than the appendix. Gallstone disease is a common disease. In the Russian Federation, more often than the gallbladder, only hernias are excised.
Doctors can not determine the exact causes of gallstone disease. Although the mechanisms of the occurrence of stones are fully understood. The most unpleasant situation is the development of cirrhosis and, as a consequence, obstruction of the biliary tract. The person turns yellow from an excess of bilirubin. The process is dangerous - there is a host of reactions from the nervous system, including the central one.
In many cases, gallstone disease is not treated. Just cut a bubble, this treatment ends. However, 40% of patients continue to experience difficulties for various reasons. For example, the high tone of the sphincter of Oddi, which does not release bile into the duodenum. Consequently, similar effects occur.
Through bile, the body removes selected substances that cannot be removed by any other means. It's about bilirubin. Only a small fraction of the substance leaves the body with urine. The other is bound in the gallbladder, enters the intestine and, finally, is broken down by bacterial enzymes. Bile acids are absorbed and re-enter the liver in a slightly modified form. The effects of enzymes of bacteria of the large intestine.
Complications of surgery
- Relapse (re-formation of stones) after cholecystectomy (removal of the gallbladder) and cholecystostomy (excision of the bottom of the gallbladder). Stones appear inside the liver, in the cult of the gallbladder, the ducts are clogged.
- Post-operative chronic (inflammatory) diseases in the stump of the gallbladder, ducts, diverticula, overgrowing of scars, the appearance of fistulas, the growth of connective or cancerous tissue, biliary pancreatitis, cirrhosis.
- Inflammatory processes of the biliary tract and the space immediately adjacent to the operation site:
- Cholecystitis stump with complications (peritonitis, abscess).
- Hepatic or renal failure.
- Mechanical jaundice.
- Damage to organs due to surgery, poor quality sutures, ingestion of foreign bodies, loss of drainage, hernia and tumor.
- Damage to the portal vein and branches, hepatic artery, pancreas, duodenum.
- Simulation of the nervous system, phantom pain, psychosis.
Often, postoperative symptoms are not related to the activities carried out, they are caused by disorders of the musculoskeletal system (neuralgia, osteochondrosis).
Complications of gallstone disease
The appearance of stones is not always noticed. Gallstone disease is divided into a number of stages, the first - latent. Causes of complications lie in the violation of the exchange of bile acids. There is poor digestibility of fatty foods, indigestion. A number of conditions described by physicians in special families are described.
Acute inflammation of the gallbladder
Cholecystitis in 90% of cases develops on the background of the presence of stones. Elderly seriously ill patients have a high mortality rate. Acute inflammation by type is divided into:
The process is preceded by an increase in the internal pressure of the body to 300 mm. Hg Art. The disease is accompanied by a violation of the outflow of bile and the appearance of specific biochemical signs. The process is inhibited by ibuprofen, indomethacin. In two thirds of cases, what is happening is accompanied by bacterial growth, mainly caused by anaerobic microbial strains. The formed circulation does not allow the patient to independently get out of the situation.
At the initial stage, the colic is pulsating (visceral), then becomes constant (somatic), the number of leukocytes and erythrocytes (deposited) increases in the blood. Against the background of symptoms, the temperature often rises, and in some cases jaundiced skin color is noted. When palpating the muscles of the right side of the hypochondrium are perceptibly tense, the bladder is enlarged. The situation worsens with gas cholecystitis, it is more common in males with diabetes.
Clinical symptoms in older people often do not correspond to the real picture of inflammation. Especially with the development of gangrenous changes in the bladder wall. When nerves die, there comes a period of temporary well-being. Appointed by additional studies, for example, ultrasound. Ultrasound can detect the presence of gases in the cavity formed by bacteria.
Sometimes the gallbladder is twisted with impaired blood supply. The pain is permanent, given in the back. Occurs more often in older skinny women. The condition is accompanied by dyspepsia, mostly nausea and vomiting. There are cases when, after dissolving the stones, it was possible to straighten the walls using electrophoresis with novocaine. Signs often resemble:
- The ulcer.
- Liver abscess.
- Pneumonia of the right side of the lungs.
Requires differential diagnosis.
Complications of cholecystitis
In addition to the development of cholecystitis on the background of stones, the disease is accompanied by complications. For example, perforation (breakdown) of the gallbladder wall with simultaneous onset of inflammation caused by the ingress of contents to adjacent organs. Most common paravesical abscess, accompanied by a number of characteristic clinical signs:
- Bubble enlarged, with palpation there is a sharp pain.
Cholecystitis manifests complications in the form of cholangitis and reactive hepatitis. As a result, the bilirubin is practically not excreted, intestinal bacteria appear in the hepatocyte cells. The blood from the portal vein is almost not filtered, poisoning the body. More often other things in bile are:
- E. coli.
- Pseudomonas wand.
It turns out, mainly representatives of the optional flora in full composition. A variety of microorganisms move into the liver. In a similar way, gallstones lead to intoxication of the body. Diagnosis of cholangitis is carried out on the triad of Charcot criteria:
- Increased fever with chills.
- Slowly growing jaundice.
- Pain in the right side.
Complications of cholecystitis include acute pancreatitis.
Empyema and dropsy
Complete obstruction of the duct causes dropsy. This happens after an acute attack of cholecystitis. The consistency of bile changes dramatically with inflammatory exudate, the bladder fills with bile, the walls become tight and sharply thin. It is characteristic that at the first manifestation of the disease there are no complaints. In case of relapse, patients complain of dull pain in the right hypochondrium. The swollen bladder is soft to the touch, slightly moving to the sides.
If an infection gets inside, pus builds up. And dropsy develops into empyema. Signs resemble a systemic inflammatory response.
On average, this complication is observed in the population in 15% of cases; with old age, the percentage rises to one third of the number of patients. The syndrome is the appearance of stones in the bile ducts. Cholesterol are formed exclusively in the bladder, the presence of similar outside the body due to migration (caused by any reasons). The state of danger is the possibility of blocking the duct completely with the development of obstructive jaundice:
- Jaundiced skin.
- Enlarged liver.
- Urine color beer.
- Colorless feces.
Older people periodically form black pigment stones. Education is accompanied by alcoholism, hemolysis or cirrhosis of the liver. Brown stones are the result of the vital activity of harmful bacteria.
The process develops in a third of cases of surgical intervention in extrahepatic ducts. The percentage of relapse reaches 6.
With overgrowing of scars the process is disturbed. The causes of the phenomenon lie in the specific action of bile or the presence of infection. When the gallstone emerges, the formation is mechanically capable of disrupting normal healing. Defects of this kind are divided into:
- Secondary inflammation.
- The consequence of sclerosing cholangitis.
- Post-traumatic strictures (up to 97% of all cases).
- Defects of bile-removing anastomoses.
Most of the accidental damage is related to operations on the stomach. When the gallbladder is removed, the complication develops in approximately 0.2% of cases. Defeat is strong or weak. In accordance with this, the level of stricture is high or low. The degree of narrowing of the duct due to tissue proliferation is:
Strictures can be divided by length by:
- Total (full length).
- Subtotal (longer than 3 cm).
- Limited (less than 1 cm).
Above the stricture the walls of the duct thicken, and below - is replaced by fibrous tissue. A key manifestation is obstructive jaundice (see above).
Secondary bilirubin-induced cirrhosis
The condition is caused by extrahepatic cholestasis, a state of a decrease in the flow of bile into the duodenum, which does not depend on the performance of hepatocytes. Developed by cholecystitis or cicatricial strictures.
As a result of this course of gallstone disease, obstructive jaundice may occur. In the intestine, the absorption of fat-soluble vitamins is impaired. The liver and spleen are enlarged. The condition develops into a syndrome of hepatic (or renal) insufficiency.
A lying stone sometimes causes necrotic changes, and cholelithiasis is complicated by perforation of the bladder walls. The clinical picture does not allow to identify the defect. An indirect sign is the sharp subsiding of pain (as a result of the release of the contents of the bladder through the hole formed). Sometimes there is abundant vomiting of bile, with which stones also come out if the formations manage to squeeze through. Ingestion of infection from the intestines leads to inflammation.
Causes and predisposing factors
Known causes of gallstone disease:
- Metabolic disorders and qualitative composition of bile with a predominance of calcium, bile pigments or cholesterol.
- Biliary dyskinesia.
- Stagnation of bile due to various pathologies (major duodenal papilla, biliary tract).
Predisposing factors include:
- Belonging to the female.
- Excessive body weight.
- Frequent pregnancy.
- Estrogen therapy.
- Genetic predisposition.
- Improper diet with plenty of fat.
- Exhausting diets.
- Certain diseases (hemolysis, diabetes, cirrhosis, Crohn's disease and others).
- Laparotomic surgery.
Quite often, the disease is asymptomatic. Gradually, with the accumulation of calculus begins to bother patients with these symptoms:
- Cramping pain in the epigastrium on the right, varying in intensity.
- A feeling of bitterness in the tongue.
- Nausea, vomiting, belching.
- Yellow staining of the skin and sclera.
Manifestations of biliary colic
This condition often accompanies gallstones. Colic is characterized by intense, unbearable pain in the right side. Pain is preceded by an error in the diet or shaking.
The pain is so severe that the patient cannot find a comfortable position. Colic may be accompanied by vomiting, if inflammation develops in the gallbladder, high fever is involved.
Possible complications of gallstone disease
What threatens gallstones?
By itself, the stone in the gallbladder poses no danger to the health and, especially, the life of the patient. A much more serious threat is the potential complications of this disease. The most frequent of these complications is hepatic colic.
A stone in the bile duct (choledocholithiasis) irritates the walls of the biliary tract, causing their spasms. Typically, this colic lasts from half an hour to an hour, and is accompanied by significant pain. If the stone is smaller than the diameter of the duct - bile, albeit with difficulty, but enters the digestive organs.
If the size of the calculus is larger than the lumen of the biliary path, it causes its blockage. The result is an increase in pressure in the organ and the occurrence of acute inflammation of the gallbladder. Such a case is an occasion for an urgent surgical operation (cholecystectomy) to remove the affected organ.
The main cause of stone formation in the biliary system is stagnation produced by the liver bile.
Gallstones and / or ducts cause inflammation of a chronic nature (chronic cholecystitis). This disease significantly reduces the level of activity of the human immune system, which, in turn, increases the risk of bacterial and viral infections of various kinds. Such inflammation is also extremely dangerous during pregnancy. In connection with all of the above, when symptoms of cholelithiasis appear (we will tell about them later), consult a gastroenterologist immediately.
If ultrasound revealed the presence of stones in the gallbladder - you must consult with the surgeon. Even the presence of a single calculus is fraught with acute surgical complications.
The surgeon will estimate the size of the stones and their number on the basis of the images obtained, which will make it possible to determine the need for surgical intervention.
Removal of the gallbladder is shown in the following cases:
- pronounced symptoms of cholelithiasis, not stopped by medications,
- progressive liver colic,
- detection in the bladder of large stones that can clog the bile duct,
- the presence of small stones, if they occupy more than half of the cavity of the gallbladder,
- dysmotility of the gallbladder,
- inflammatory process,
- increased pressure in the hepatic bile ducts,
- localization of the stone near the entrance to the common bile duct.
The inflammation of this organ is called cholecystitis. If it is acute, removal (cholecystectomy) is inevitable.
The clinical picture of acute cholecystitis with gallstones is as follows:
- acute pain syndrome of a cutting or spasmodic character in the area of the right hypochondrium, which does not pass more than one hour,
- dull pains in the same area, lasting more than two hours,
- pain syndrome can not be stopped by antispasmodics,
- pains spread throughout the abdomen,
- body temperature exceeds 37 degrees,
- repeated vomiting.
Cholecystectomy for acute cholecystitis caused by cholelithiasis is mandatory, and removal of the affected organ is urgently needed.
In such cases, the time for preoperative preparation of the body simply does not remain. In this connection, even in the absence of colic and acute cholecystitis, with cholelithiasis, experts often recommend elective cholecystectomy, since in this case there is time to calmly prepare for the operation and minimize its trauma.
The doctor is obliged to conduct diagnostic activities in full, excluding other pathologies, to determine the severity of the condition. As a rule, patients go to a doctor after an attack of hepatic colic, pain causes considerable discomfort and is prone to recurrence.
It is important that the doctor collects a full history and find out how the disease began, how it proceeded, what medications helped, the nature of the onset of attacks, to trace the connection between the disease and nutrition. Then the examination and identification of symptoms of calculous (cholelithiasis) cholecystitis - Kera, Murphy, Ortner-Grekov and others. The color of the bile covers and sclera is evaluated, jaundice starts from there.
After the consultation, instrumental diagnostics of gallstones is performed:
- Ultrasound examination - in most cases reveals a gallstone calculus.
- X-ray of the abdominal cavity:
- Survey radiograph - aimed at identifying calculus with a large amount of calcium in the composition.
- The study with the introduction of contrast in the gallbladder - allows you to find stones that are not visible on standard X-rays.
- CT and MRI can distinguish even small stones in the gallbladder, used for differential diagnosis.
- Endoscopic retrograde cholangiopancreatography helps assess the condition of the bile ducts, detect calculi and volumetric neoplasms.
Laboratory diagnostics is carried out - the level of bilirubin and inflammation markers (CRP, ESR, leukocytosis and others) are determined in the blood.
Patients who do not know where to turn for cholelithiasis should make an appointment with a gastroenterologist. The doctor will conduct a full examination and determine the next steps for treatment. Self-treatment is strictly prohibited, can harm. For example, the use of cholagogue in the presence of stones leads to complications.
If the stones are small (up to 3 cm.), There are few formations, it is permissible to try conservative therapy. This includes resorption of calculi through the introduction of special medications, remote shock-wave lithotripsy, percutaneous transhepatic cholelitholysis, and others.
In what cases can you avoid surgery?
With stones in the gall bladder surgery is not always required.
Cases when it is possible to remove calculus without surgery:
- the calculi are small in size (much smaller than the diameter of the common bile duct),
- one large or small number of large stones (two or three), the location of which allows their crushing using shock-wave lithotripsy (ultrasound).
With this diagnosis, it is possible to derive the calculi in a natural way with the help of choleretic preparations. In such cases, occasional colic is possible, but only when the stone touches the wall of the common bile duct. Such colic usually goes away quickly, and pain syndrome is easily stopped by antispasmodics (for example, no-spy).
However, in fairness, it should be said that the natural removal of small stones or crushed remnants of large stones does not solve the main problem that led to their formation. Stagnation of bile does not disappear anywhere, and violations of its chemical composition also remain. Therefore, relapses occur in most cases, and stones are formed again.
Possible non-surgical complications
From the moment of formation in the gallbladder stone to the time when surgery will be necessary, it may take several years, during which the patient must carry out medical recommendations.
Options for conservative treatment of gallstone disease:
The simplest is the first treatment option, since there is no pain and the risk of complications is low. However, even this treatment does not exclude the possibility of complications associated with organs such as the liver, pancreas and small intestine.
The appearance of colic indicates that a stone from the gallbladder got into the common bile duct and came into contact with its walls. If the calculus diameter is larger than the diameter of the duct, then it clogs its lumen. The outflow of bile is disturbed, the pressure in the gallbladder increases, which leads to the acute form of cholecystitis. The operation in this case is complicated by the fact that in addition to the removal of the affected organ, you also need to somehow remove the calculus from the duct.
Chronic cholecystitis develops as a result of stretching the walls of this organ with stones and stagnation of bile in it. This is dangerous because it creates a favorable environment for the reproduction of pathogenic bacteria. Chronic inflammatory process prevents the accumulation of bile, and the affected gallbladder is no longer able to push it into the small intestine in portions.
Another complication of cholelithiasis is an increase in pressure (hypertension) in the hepatic bile ducts due to stretching with bladder wall calculi.
Such hypertension appears already half a year after the formation of stones and causes a disruption in the normal functioning of the liver cells.
Against the background of the chronic form of this disease, non-infectious type hepatitis occurs, destroying liver cells. If you do not take action in time - perhaps the appearance of more serious diseases - fibrosis and cirrhosis of the liver.
In rare cases, but gallstone disease can cause cancer of the liver and gallbladder. This development of the process is possible with the chronic form of the disease, long-term inflammation and long-term congestive processes, if, moreover, effective treatment is not carried out. Cancer of an organ such as the gallbladder can damage the liver in a short time, and then treatment will be very difficult.
Drug dissolution of stones
For this method of therapy used drugs containing ursodeoxycholic and chenodesoxycholic acid. Substances dissolve calculus containing excess cholesterol. Usually the method is used when the stones are small (4-16 mm). When choosing a method, the contractility of the gallbladder should remain normal.
Medications are applied for a long course from six months to two years under the supervision of a physician. In most cases, the method helps, but the disease can reappear. Preventing relapse, you will need to continue taking medication in small dosages.
Prevention of complications of cholelithiasis
The risk of any undesirable complications can be assessed only by a qualified doctor. If you promptly seek medical help and receive the recommended therapy, such negative consequences can be avoided.
Here are a few simple recommendations, following which you can minimize the risk of the appearance of dangerous effects on stones in the gallbladder:
- following a diet during the whole period of treatment of the disease, as well as after it, even once having violated the recommended diet and diet, it is possible to provoke colic or acute cholecystitis,
- strict adherence to the rules of taking prescribed drugs, refusal of drug therapy or unplanned interruptions in it significantly increase the risk of serious complications of this disease,
- Do not self-medicate and do not change the prescribed drugs yourself (without consulting the doctor), this can disrupt the whole regimen of treatment and lead to a sad result, it should be remembered that if there was no drug at the pharmacy, only your attending physician can replace it, but not the seller,
- Ultrasound of the liver and gallbladder should be performed at least once every six months, with the same frequency it is necessary to consult with the surgeon,
- A visit to a general practitioner or a gastroenterologist is necessary at least once every three months,
- a stool test should be taken once every six months,
- give up smoking, nicotine and so harmful to the body, so it still provokes the thickening of bile, leading to the formation of biliary stones.
If you follow the above rules, the risk of serious complications is significantly reduced, and the process of formation and growth of stones in the gall bladder slows down and is amenable to medical control.
Remote shock wave lithotripsy
The method is designed to crush a large stone in the gall bladder into many small ones, often used in conjunction with the previous method. The first step is crushing large stones. The second is the drug dissolution of the resulting small fragments.
The shock-wave lithotripsy harbors many dangers, during the procedure the bile duct can become blocked or the gallbladder can be damaged. There is a need for surgical intervention.
The operation helps the majority of patients, rarely (two out of ten cases) there are consequences of treatment or residual effects that have not disappeared after the operation, united by the name postcholecystectomy syndrome. These include:
- Lesions of the biliary tract, not associated with the gallbladder (disorders in the sphincter of Oddi, calculus choledochus).
- Postoperative complications (adhesions, hernia, damage to the bile ducts, the formation of stones in the cult of the bladder and others).
- Diseases caused by biliary stones, but not stopped after surgery (biliary pancreatitis, hepatitis).
Properly chosen treatment brings relief from the disease; at the first signs of gallstones, it is necessary to seek medical help.
If a person has a tendency to the formation of stones in the biliary tract or education occurred, but removed, it is extremely important to adhere to a special diet. It is required to eat often (6 times in females) in small portions. With such a diet, the release of bile through the duodenal papilla is constantly stimulated, the secret does not stagnate. If the portion is too large, the motility of the gallbladder increases, which in the presence of calculus can lead to inflammation.
The diet is supposed to be balanced, filled with nutrients, vitamins and microelements. It is recommended to use low-fat varieties of meat and seafood, low-fat dairy products, cereals, especially oatmeal and buckwheat, vegetable foods (fruits, vegetables, herbs, dried fruits), compotes, juices, mineral waters. Consumption of fatty, fried, spicy foods, foods with a high content of caffeine, smoked meats, canned foods, garlic, cucumbers, beans is not recommended.
How to do without surgery and live with stones in the gallbladder
Is it possible to live without surgery at JCB? And how old? With a stone, you can live without surgery. But it is important to change the diet, to give the body moderate exercise, to take drugs prescribed by the doctor. In each case, only the doctor decides whether or not to have surgery.
Gallstones - symptoms, causes and treatment.