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Gallstones: Examination, Diagnosis & Treatment
Examinations & Diagnosis
"Dumb" gallstones that do not cause pain are often found only by chance during a routine ultrasound examination of the upper abdomen. The laboratory values of these patients are normal.
If gallstones cause symptoms, a suspected diagnosis of gallstone disease can often be made from the description of the symptoms. Ultrasound and blood tests are usually sufficient to confirm the suspicion. Further investigations, such as B. Magnetic resonance imaging of the biliary tract (MRCP) or endoscopic ultrasound only need to be carried out if there are special questions to be clarified. Gallstones can be detected on x-rays if they are calcified or if a contrast agent has been injected into the biliary system.
Upper abdominal sonography is the method of choice for diagnosing gallstones. Gallstones in the gallbladder can be clearly seen on the ultrasound image from a size of 1-2 millimeters. The wall of the gallbladder is typically delicate (1-2 mm) and, in acute inflammation of the gallbladder (cholecystitis), thickened and usually accentuated with an accumulation of fluid (edema) around the gallbladder; Stratification of the gallbladder wall is typical of cholecystitis. Dilated bile ducts are an indirect sign of stone-related bile duct obstruction. Direct sonographic detection of stones in the bile duct is only rarely possible.
In typical biliary colic, normal blood values are usually found. Only when a complication such as inflammation of the gallbladder (cholecystitis) occurs do increased inflammation values (leukocytes, CRP) appear. The bilirubin concentration in the blood increases as a result of the backlog of the bile. The values for the enzymes gamma-glutamyl-transferase (Gamma-GT) and alkaline phosphatase (AP) are then also increased. In the case of stone-related inflammation of the pancreas (biliary pancreatitis), the value for the enzyme lipase is increased.
Endosonography and magnetic resonance tomography
If bile duct stones cannot be detected using conventional ultrasound, endosonography (endoscopy with an ultrasound device built into the endoscope) can clarify the situation. The doctor guides a special endoscope through the esophagus and stomach into the duodenum to the bile duct opening (papilla Vateri). There, the bile duct and any stones can then be precisely assessed endosonographically through the duodenal wall. If the method of endosonography is not available, the biliary tract can be examined similarly well using special magnetic resonance imaging (MRCP = magnetic resonance cholangiopancreatography).
The treatment depends on the severity of the symptoms caused by the gallstones (pain, colic, fever or even jaundice). In the case of acute biliary colic, the doctor will first prescribe anti-inflammatory, analgesic and antispasmodic agents, as well as a strict zero diet. If the gallbladder is inflamed, he will also give antibiotics. After a colic, the person affected should only start a light diet again after a few hours.
If attacks of pain are repeated or if there is an acute inflammation of the gallbladder, the gallbladder usually has to be removed. There are a number of methods for doing this, as outlined below.
Only so-called "silent" gallstones, which are not noticed by their carriers and found purely by chance during an ultrasound examination, do not require any treatment.
After gastric bypass surgery, preventive ("prophylactic") medication is advisable to prevent the formation of stones, which often occurs.
If the patient's general health allows, the doctor may remove the gallbladder during a laparoscopy. For this he will wait for a symptom-free period if possible. An acutely inflamed gallbladder, on the other hand, usually has to be removed quickly within a few hours to days, especially in the case of severe inflammation of the gallbladder (cholecystitis), an open abdominal operation with an incision may be necessary instead of a gentler laparoscopic operation.
Endoscopic retrograde cholangiography
The doctor can remove stones in the bile duct with the help of special cups. For this purpose, a special endoscope (duodenoscope) is presented via the esophagus and stomach into the duodenum to the bile duct opening (papilla Vateri). The bile duct is then probed, stained with an X-ray contrast medium and displayed. Since this is done from the point of the mouth and endoscopically, this method is called endoscopic retrograde cholangio-pancreatography ("ERCP" for short). In order to pull stones out of the duct, the junction usually has to be widened a little, which is done by means of a small incision over an electric wire (so-called papillotomy or sphincterotomy). Very large or stuck stones can be crushed with additional methods and then removed ("mechanical lithotripsy", laser or electrohydraulic lithotripsy, extracorporeal shock wave lithotripsy (= "ESWL").
Non-calcified cholesterol stones can be resolved by regularly taking a certain bile acid (ursodeoxycholic acid). The process of stone formation is reversed here. The prerequisite is that the stone is very small and the gallbladder is still fully functional and there is no chronic inflammation. However, the treatment lasts 12-18 months, and even then the stones are no more than 70% dissolved. The risk of getting stones again within five years is relatively high (over 50% of cases). This is why this method is only used today in specially selected individual cases.
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