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[Special Topic on Gallstones]Stones falling into the bile duct can cause pain and bloating, and gallbladder removal can prevent future complications.

[Special Topic on Gallstones]Stones falling into the bile duct can cause pain and bloating, and gallbladder removal can prevent future complications.

Reported by: Yang Qianni Edited by: Liang Yingxiu

(Kuala Lumpur News) If gallstones have fallen into the bile duct and caused symptoms, the chance of recurrence in the future is 100%. It is only a matter of time.

Therefore, as long as gallstones have caused symptoms such as pain or flatulence, inflamed the gallbladder, or caused complications such as jaundice and pancreatitis, you need to undergo cholecystectomy to avoid future problems.

Bile is secreted by the liver and has the function of digesting fat and assisting in the metabolism of cholesterol, drugs and toxins. The formation of gallstones is related to bile.

Bile has complex components, the three most important ones being cholesterol, bile salts and lecithin. They remain in a state of equilibrium and dissolve in bile. When there is too much of one of the ingredients, causing an imbalance in the ratio, insoluble ingredients are likely to appear, which may precipitate to form gallstones.

Consultant Hepatogastroenterology Datuk Dr. Tan Xueyu

Bile is concentrated to form gallstones

Dato’ Dr. Tan Huck Joo, Consultant of Hepatoenterology and Gastroenterology, pointed out that you can think of it like when you add too much chocolate powder and too little water when brewing a drink, some ” lumps” and the drink becomes thicker. Therefore, as long as there are any factors that cause excessive cholesterol and destroy the ratio of the “golden triangle”, gallstones may occur.

“In addition, the gallbladder is an organ responsible for concentrating and storing bile. When people eat, the body secretes a special hormone, cholecystokinin (CCK), which prompts the gallbladder to contract and expel bile to flow into the duodenum to aid digestion. If If any problem affects the contractile function of the gallbladder, bile will easily remain and continue to be concentrated, and gallstones will easily form.”

He said that hormonal problems are also one of the risk factors for gallstones, and the risk is relatively higher in women. For example, the increased secretion of progesterone during pregnancy can cause gallbladder contraction and reduced peristalsis. Therefore, pregnancy or multiple pregnancies, as well as oral contraceptive pills, also increase the chance of gallstones.

He further explained that older people, such as women over 40 years old, obese people who have lost a lot of weight, fasted for a long time, or suffer from metabolic syndrome, such as diabetes or high cholesterol, are all at high risk for gallstones. “Although some cholesterol-lowering drugs can reduce blood cholesterol, they can increase the cholesterol content in bile. In addition, bacterial infection can also affect the contraction of the gallbladder.”

“Some gallstones can cause symptoms, or when the stones fall into the bile ducts and cause obstruction, they may cause pain and gas, which are very similar to the symptoms of stomach problems. Because of this, many patients with ‘stomach discomfort’ don’t know In fact, it’s gallstones that are causing trouble, and even doctors often treat it as a stomach problem.”

Abdominal pain and associated back pain

How to identify the two? He revealed that the gallbladder is located in the right upper abdomen, so pain usually occurs above or on the right side of the abdomen. Typical symptoms include back pain. “In addition, the symptoms caused by gallstones usually last for 20 to 30 minutes, or even about 2 hours, and then disappear completely, and may not appear abnormal for the next few days; this is not the case with stomach pain. However, the common situation is When the patient felt abdominal pain, he happened to take the stomach medicine at hand and tried it. The pain ‘really’ relieved soon after, so he mistakenly thought that the stomach medicine was effective, but this was not the case.”

He reminded that it should be noted that gallstones that cause symptoms should not be taken lightly. In addition to causing cholecystitis, gallbladder pyometra, cholangitis, etc., they can also cause life-threatening acute pancreatitis.

“Gallstones are mainly treated through cholecystectomy, which is also the most effective way to prevent recurrence and complications of gallstones. However, not every patient needs to have their gallbladder removed.”

Treatment mainly depends on three factors. First, the gallstones cause symptoms such as pain or flatulence. Second, the gallbladder is inflamed. Third, it causes complications such as jaundice or pancreatitis. If one of these conditions applies, the gallbladder must be removed.

Because stones in the gallbladder can easily attract bacteria, which can lead to infection and inflammation, the gallbladder can cause pain and other symptoms, and the patient may also have a fever.

After the bile secreted by the liver is discharged from the gallbladder, it flows into the duodenum through the bile duct, and the pancreatic juice secreted by the pancreas on the side also helps in the digestion of food. Bile and pancreatic juice share a common outlet, the duodenal papilla.

No need for oral hygiene after gallbladder removal

He said that if the stone falls into the bile duct and causes obstruction, the bile pigment metabolized by the liver cannot be excreted, and the patient’s skin color and sclera will turn yellow, which is jaundice. If left alone, bacterial infection, suppuration, or fever may develop. “

If the stone goes further down and gets stuck in the duodenal papilla, the problem will be even greater. Failure of pancreatic juice to be discharged smoothly can cause acute pancreatitis, and the patient may be in danger of life. Fortunately, acute pancreatitis usually causes symptoms such as severe pain, vomiting, or fever, and patients usually seek medical attention promptly.

If gallstones once fell into the bile duct and caused symptoms, the chance of falling out again in the future is 100%. It is only a matter of time. Therefore, patients who meet the three conditions mentioned previously must have their gallbladder removed to avoid future problems.

“Why can’t we just remove the gallstones? First of all, if the gallbladder has formed gallstones in the past, it often means there is something wrong with it. If you just remove the gallstones, gallstones will still appear in the future because the risk factors are still there.”

Secondly, the gallbladder actually has no function. Many patients will vehemently object to the doctor saying “remove the gallbladder” when they hear it, but they will be very willing to “save the gallbladder and remove the stones” because they think they will not be able to digest fats after losing their gallbladder. In fact, bile is secreted by the liver, and the gallbladder is only responsible for concentrating, storing and excreting bile.

Cholecystectomy is one of the most common and most commonly performed surgeries in the world, with millions of people undergoing it every day. After their gallbladder is removed, their lives go back to normal and they don’t need to take any special precautions.

There are misunderstandings about gallbladder removal

For gallstones that cause symptoms, surgical removal of the gallbladder is a once-and-for-all treatment, otherwise the chance of recurrence in the future is 100%. However, there are too many myths about gallstones in society, including “natural stone removal therapy” and the “consequences” of gallbladder removal, which often cause some communication barriers between doctors and patients.

When he recalled a past incident, he said that he still remembered a boss of a listed company who came to see a doctor because of gallstones. Coincidentally, his wife had undergone a cholecystectomy 20 years ago. This time the exact same thing happened to her partner, but she strongly opposed her husband’s surgery. When I asked her why she was like this, she got the answer “They said you can’t eat greasy food after having your gallbladder removed.” Regardless of who “they” were, I asked her if there were any abnormalities after the gallbladder was removed. She said no.

This makes people laugh and cry – in this case, why are you still unwilling to let your husband undergo surgery? “

Even “people who have been there” can fall into this myth, which shows how many people around us are convinced of the misunderstanding about gallstones.

In fact, this phenomenon is not common abroad. Chen Xueyu has practiced medicine in the UK for 10 years and has never encountered a patient worried about dietary restrictions after gallbladder removal. Other Malaysian friends do not have such problems, but strangely, almost Every Chinese has this idea.

“I don’t know whether it is because of myths or other reasons, but several patients have delayed gallbladder removal for three years. In some cases, the gallstones in some patients have caused complications, and we cannot remove the gallbladder right away. Instead, endoscopic retrograde cholangiopancreatography (ERCP) is first used to remove the stones blocking the bile ducts, and then a stent is inserted to open the small bile ducts. After the liver swelling or jaundice subsides, surgery is performed to remove the gallbladder. “

He also revealed that a patient had cholecystitis in 2019 due to stones blocking the bile duct.

“He was supposed to have the stent removed and the gallbladder removed within 3 months after undergoing ERCP. However, since he felt no discomfort after ERCP, he decided not to come for treatment. It was not until January 2022 that he suffered from gallstone pain again. and fever. See a doctor. At this time, the stent has been in the body for 3 years. Because the gallstones fell out again, the bile duct has been completely blocked and even suppurated.”

Small particles are more likely to fall into the bile duct

The bigger the stone, the more dangerous it is?

Gallstones were discovered in a patient who presented with abdominal pain during pregnancy. To avoid developing life-threatening acute pancreatitis, she needed emergency treatment.

Due to the special circumstances, ERCP is particularly difficult to perform. In addition to shortening the operation time, the patient also needs to maintain a prone sleeping position during the process, which will put pressure on the abdomen.

Chen Xueyu pointed out that generally ERCP is performed with a combination of endoscopy and X-ray equipment, but this time it had to be converted to ultrasonic equipment, which added to the difficulty. After the stent was placed, her condition improved. Unexpectedly, because she was too busy taking care of her children, she did not come back until 3 years later to have her gallbladder removed. Fortunately, no adverse consequences occurred.

Ultrasonic accuracy 90%

Ultrasound examination is the preferred method for diagnosing gallstones, with an accuracy of up to 90%. Computed tomography (CT) scans are similarly accurate. However, neither test can detect gallstones that are too small.

Chen Xueyu said that now there is a better method, namely endoscopic ultrasound (EUS). The gallbladder is right next to the duodenum, so an endoscope can be inserted into the stomach to see clearly the condition of the gallbladder.

“Many times, patients have received ordinary ultrasound, CT scans or even magnetic resonance imaging (MRI) but no abnormalities are found, and they are suspected of having gastric problems. However, the symptoms are still not relieved after giving gastric medicine, so we will recommend EUS.”

Symptoms independent of stone size

EUS is an invasive examination and is very accurate. Many patients have discovered “sand grains”, that is, very small gallstones, in the gallbladder. After the gallbladder is removed, the symptoms disappear.

In addition, this also confirms from the side that symptoms have nothing to do with the size of gallstones. After some patients discover gallstones, they undergo ultrasound examinations every year to “measure” whether the gallstones have grown in size, thinking that the larger the size, the more dangerous they are. In fact, the situation is exactly the opposite. Smaller gallstones are easily “squeezed out” by the gallbladder and fall into the bile duct, causing obstruction.

Taking this opportunity, he will also dispel common myths about gallstones one by one, hoping that the public can obtain correct information and receive appropriate treatment after diagnosis!

drug treatment

Effectiveness is only 10%

Question 1: Is there any drug treatment for gallstones?

Answer 1: Yes, but it is very ineffective. Generally, it is used as an alternative treatment for patients with high risk of surgery, or for those patients who firmly believe in myths and are determined not to undergo surgery. We only allow them to receive medical treatment when we have no other options. The commonly used drug is ursodeoxycholic acid, which mainly reduces the concentration of cholesterol in bile to facilitate dissolution.

However, patients need to continue taking it for a long time, about one or two years, and the chance of effectiveness is only about 10%.

Both types of gallstones have the same symptoms

Question 2: How many types of gallstones are there?

Answer 2: There are two main types of gallstones. Depending on their composition, they can be divided into cholesterol stones and pigment stones. The former are white, accounting for about 80%; the latter are black, accounting for about 20%. Regardless of the type of gallstones, the symptoms and complications are the same.

Asymptomatic stones require no treatment

Question 3: Is it possible to have gallstones but not find them?

Answer 3: In fact, many people have gallstones but are asymptomatic. They may have accidentally discovered several stones in their gallbladder during an ultrasound scan during a routine health check-up.

It is important to note that asymptomatic gallstones do not require any treatment as they may not develop any symptoms during their lifetime.

Therefore, observation and waiting is the best approach, and treatment is not initiated until symptoms appear.

Gallbladder removal requires general anesthesia

Question 4: Does gallbladder removal require general anesthesia?

Answer 4: Whether it is traditional laparotomy or the now common laparoscopic cholecystectomy, general anesthesia is required. The latter is a simple minimally invasive surgery. The doctor will make 4 small holes in the patient’s abdomen, use laparoscopy to observe and remove the gallbladder, and remove it together with the stones from the outside of the body. The operation lasts about 45 minutes to 1 hour, and patients can usually be discharged from the hospital the next day.

Eat fried food after gallbladder removal

Question 5: After the gallbladder is removed, can I not eat any oil?

Answer 5: I have clarified this point many times, but many people still ask the same question. Quite the opposite is true!

When you have gallstones, it is not recommended to eat fried or greasy food due to symptoms such as pain, discomfort, or flatulence. This is because when we eat, the body secretes cholecystokinin (CCK) to cause the gallbladder to contract and expel it. Bile aids digestion. When the gallbladder contracts, the patient will feel more pain.

Therefore, it is best for patients with gallstones to reduce greasy food, which can alleviate symptoms. Moreover, whenever the gallbladder contracts, the stones inside will “run” out, increasing the risk of blocking the bile duct.

However, after patients have their gallbladder removed, it is okay to eat greasy or fried foods. Not only will they not cause symptoms, there is no risk of gallstone obstruction.

Removing the gallbladder does not affect digestion

Question 6: After removing the gallbladder, there is no bile and the oil cannot be digested?

Answer 6: Many patients are worried that if the gallbladder is removed, they will need to stop eating and will no longer be able to “enjoy the pleasure of eating”, especially greasy and fried food. This is because they think that bile is secreted by the gallbladder. Once the gallbladder is removed, the body will no longer be able to produce bile. This is is wrong.

Bile is actually secreted by the liver, so cholecystectomy will not affect the secretion of bile, nor will it affect the digestion and absorption of greasy food.

Stone size and number are not important

Question 7: The bigger the gallstones are, the more dangerous they are. Is it best to check them every year to see if they are getting bigger?

Answer 7: Many times patients will want to know how big their gallstones are and how many there are. In fact, this is not important at all to doctors.

First of all, gallstones are not uniformly manufactured in factories and will not be perfectly shaped. Each stone is different in size and uneven. Maybe if you measure it “horizontally” you’ll get 1 centimeter, but if you measure it from another angle you’ll get 7 millimeters, so it’s impossible to get an accurate number.

Secondly, whenever we use ultrasound or CT scanning, the results obtained are two-dimensional (2D) images rather than three-dimensional (3D) images.

This means that there may be “blind spots” in the scan. For example, you may see 3 gallstones in the first examination, but you may only see 2 in the second examination because one of them “rolled” to the back and was blocked by the larger gallstones in the front. The stone blocked it.

Therefore, the number of gallstones is likely to be missed.

There are also patients who will try “natural stone removal therapies” such as apple cider vinegar on their own, and then go back for a check-up a week later. If a few gallstones are blocked at this time, it will make them think that the treatment is effective and the stones have been expelled. In fact, it is impossible to expel gallstones through this kind of “therapy”.

Therefore, the focus is not on the number and size of gallstones, nor is this what doctors consider when deciding whether a patient needs cholecystectomy. Some patients think that if the gallstones are small, they do not need treatment. In fact, the smaller the gallstones, the higher the chance of falling into the bile duct. The most important thing is whether gallstones have ever caused symptoms.

No drugs can dissolve gallstones

Question 8: After drinking apple cider vinegar and olive oil, are “gallstones” really eliminated?

Answer 8: In fact, there is no drug that can “dissolve” gallstones and allow them to be excreted through the intestines and stomach. If you understand the structure of the human body’s organs, you will understand that the “stones” they claim to be expelled are definitely not gallstones.

After the gallbladder contracts, bile is transported to the bile duct and then flows into the duodenum to aid digestion. This small bile duct is usually only 3 to 4 mm, which is about the thickness of three A4 papers. If it is larger than 7 mm, it is classified as dilated, which means that the bile duct may be blocked. Therefore, once gallstones fall into the bile duct, they will almost certainly “get stuck” in the passage and cause symptoms.

The lumens of the small intestine and large intestine are relatively large, so if gallstones reach the small intestine, there will be no problem. However, even if the gallstones “smoothly” move down the bile duct and reach the opening shared with the pancreas, the duodenal papilla (major duodenal papilla), they will definitely cause obstruction, because this area is only the size of a pen tip, and the gallstones cannot pass through it at all. A small “spot” enters the small intestine. It’s like trying to drive a bus into your home. It’s impossible because the door is too small.

Many patients who tried natural remedies took photos to show me. These “stones” are not small and cannot enter the small intestine, let alone be excreted from the large intestine.

If there were truly an effective “home remedy” to expel gallstones, cholecystectomy would have been eliminated long ago. Just like before the discovery of Helicobacter pylori in the 1980s, many patients with gastric or intestinal ulcers and bleeding were treated with surgery. Nowadays, Helicobacter pylori can be treated with antibiotics, and many doctors have forgotten how to perform gastric ulcer removal surgery.

Text editing: Chen Xiaoquan

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