This article is about Gallstone disease (SCI) is a multifactorial and multistage disease characterized by impaired cholesterol and bilirubin metabolism with the formation of stones in the gallbladder and bile ducts. Gallstone disease is one of the most common human diseases. It ranks third after cardiovascular disease and diabetes.
Key words: cholelithiasis, gallstones, pigmented stones,bilirubin, cholesterol, cholecystectomy, cholecystitis. Since the gallbladder and bile ducts are the site of congestion and even the concentration of bile, it is bile, its components under certain conditions are the source of stone formation.
Bile on 85-95% consists of water in which there are bile acids, cholesterol, phospholipids, bilirubin, proteins, electrolytes. The main components are bile lipids (fats) and pigments. The main lipids of bile - cholesterol, phospholipids and bile acids - is a product of lipid metabolism of the liver. The main bile pigment - bilirubin - is the final product of the decomposition of hemoglobin released when old or inferior erythrocytes are destroyed. Most gallstones are mixed. They include a significant number of organic and inorganic substances: cholesterol, bilirubin, bile acids, proteins, various salts, calcium, trace elements. However, according to the prevalence of components, cholesterol, pigment and mixed stones are distinguished.
The most common cholesterol stones, the main component of which is cholesterol. Pure cholesterol is round or oval, usually 4-5 to 12-15 millimeters in diameter, almost always in the gallbladder. The predominantly cholesteric mixed stones have a layered structure or consist of a pigmented central part surrounded by a thin layer of cholesterol. Lime and pigment - the main impurities of cholesterol stones - form cholesterol-pigment- calcareous stones. They, as a rule, are multiple, occur in tens or even hundreds.
Purely pigmented stones of small size, hard, brittle. Contain mainly bilirubin and its polymers. There are black and brown pigmented stones. As a rule, multiple, are located both in the gall bladder and in the bile ducts.
Very rarely there are pure calcium stones, consisting of calcium carbonate. Their form is usually bizarre, often with spike-like processes. The color of the stones is light to dark brown.
The causes of the formation of cholesterol and pigment stones of the biliary tract are different, because they are formed from different components.
The formation of cholesterol stones is caused by three main factors: bile supersaturation with cholesterol, precipitation of cholesterol salt in the form of crystals and dysfunction of the gallbladder. In other words, when there is a lot of cholesterol in the bile, and its normal excretion is disrupted.
Cholesterol stones are formed only in the gall bladder, any cholesterol stones found in the common bile or common hepatic ducts should be considered as migrating from the gallbladder. Black pigmented stones are usually formed in elderly patients with hemolysis, alcoholism and cirrhosis of the liver; they also appear in the gallbladder and rarely migrate into the ducts. Most pigmented stones in the ducts are brown pigmented stones. They are formed in the ducts as a result of bacterial enzymatic action on bile pigments and phospholipids and are often accompanied by recurrent purulent cholangitis.
Endoscopic methods for diagnosis of cholelithiasis are performed using endoscopic devices (fiber-optic video endoscopes). These include endoscopic cholangiopancreatography and choledochoscopy.Endoscapic retrograde cholangiopancreatography is the "gold standard" in the diagnosis of cholangiolithiasis (efficacy 80-99%), is a combination of endoscopic and radiologic methods. It is important to note that endoscopic cholangiopancreatography from the diagnostic procedure can be transformed into medical (endoscopic papillotomy, extraction and crushing of stones, nasopharyngeal drainage with purulent cholangitis, bilious hypertension, etc.), so its use is especially important in complicated cholelithiasis.Choledochoscopy is the most accurate method of diagnosing stones in the bile ducts. It can be performed in two ways: ingra-operatively (with laparotomy and laparoscopic operations) and with duodenoscopy, when a thin endoscope (baby-scop) is guided through the working canal of the endoscope through the large duodenal papilla to the bile duct.
Until recently, there м only two methods of treatment of cholelithiasis: surgery or conservative therapy. The majority of specialists today continue to consider that patients with cholelithiasis in the presence of repeated biliary colic attacks, development of acute cholecystitis and their complications, as a rule, are subject to surgical treatment, that is, surgery.
Conservative therapy is performed with asymptomatic and dyspeptic forms of the disease or in the inter-attack period of the painful form, and is also prescribed to patients with contraindications to the operation. Drug treatment is aimed at reducing inflammation of the gallbladder, an improvement in preoperative preparation.
The main operation in the surgical treatment of cholelithiasis is the removal of the gall bladder only by stones - cholecystectomy. Today, throughout the world, the main method of surgical removal of the gallbladder is a laparoscopic (from the puncture of the abdominal wall) cholecystectomy, at which the endovideosurgical technique is used. But in some cases, a traditional operation is performed - through the incision of the abdominal wall.
So, from the existing methods of treatment of cholelithiasis the most effective is surgical - removal of the gallbladder. At planned operations in patients with uncomplicated cholelithiasis, postoperative lethality does not exceed 0.5%. It is important to promptly reveal the indications for the operation, without waiting for the development of complicated forms of the disease.
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