Gallbladder stones "do not feel", can you ignore it?

The vast majority of patients with gallbladder stones do not feel it for a considerable period of time after the disease. Since there is no pain, no itching, and no symptoms, do gallbladder stones still need treatment?

At the end of 2021, the Expert Consensus on the Surgical Treatment of Benign Diseases of the Gallbladder (2021 Edition) (hereinafter referred to as the "Consensus") was released, which aroused widespread concern and heated discussion in the academic community. At the heart of the debate is the new Consensus on including asymptomatic gallstones in the scope of indications for cholecystectomy.

The new consensus emphasizes that cholecystectomy is the only cure for benign gallbladder disease, and that surgical indications include asymptomatic gallbladder stones, that is, asymptomatic gallbladder stones also recommend surgical removal of gallbladder treatment.

Gallbladder stones are mostly "silent"

Gallbladder stones are a common disease, frequent disease, often secondary to cholecystitis, cholangitis, pancreatitis and gallbladder cancer, seriously endangering the health of patients and consuming a large amount of medical resources. The incidence of gallbladder stones is high, with 1 to 2 out of every 10 people worldwide having gallbladder stones.

The vast majority of patients do not have significant symptoms for a considerable period of time with gallbladder stones. Many people only find gallbladder stones through ultrasound examination during health checkups. Gallbladder stones cause abdominal pain only when they block the gallbladder ducts, a condition that is mostly precipitated by a high-fat diet. The gallbladder contracts strongly, stones are embedded in the gallbladder duct, and the discharge of bile is blocked, unable to enter the extrahepatic bile ducts and intestines, resulting in increased gallbladder tone, biliary tract inflammation and spasm, and biliary colic.

Typical biliary colic is a spasmodic pain in the right upper quadrant that radiates to the right shoulder and back, lasts from a few minutes to ten minutes, and mostly resolves on its own. If gallbladder obstruction does not resolve, abdominal pain persists and paroxysmal exacerbations, and secondary bacterial infection and purulent biliary tract infection may occur. At this time, the patient will have symptoms of acute cholecystitis and cholangitis such as fever, sclera or skin yellowing.

Some patients with gallbladder stones present with sudden abdominal pain and are finally diagnosed with acute abdomen caused by gallbladder stones. Worse still, gallbladder stones are excreted into the extrahepatic bile ducts, causing obstruction of the opening of the distal bile duct to the duodenum or pancreatic duct, and life-threatening acute cholangitis or severe acute pancreatitis is detected.

Gallbladders with stones are more susceptible to cancer

The view in the previous consensus was that "asymptomatic gallbladder stones are observable, and symptomatic gallbladder stones are recommended for surgical treatment with gallbladder resection." This concept of treatment has been written into the textbooks of undergraduate education for medical students in mainland China, and has been implemented as a medical norm for decades, which is naturally the concept held by most doctors at present.

Asymptomatic gallbladder stones can be observed on the basis that some patients may remain asymptomatic (autopsy studies have found that such conditions account for about 50%) and that no serious secondary lesions have occurred. If there are no symptoms, you can observe and follow up regularly, and then treat them accordingly when symptoms appear.

Symptomatic surgical treatment of gallbladder stones is based on the fact that there is no recognized effective treatment to remove the stones completely. There is a great risk of litholysis and stone removal therapy, and if gallbladder stones are embedded in the gallbladder duct or discharged into the common bile duct during stone removal, causing bile duct obstruction, or even at the outlet of the pancreatic duct, it will lead to acute obstructive purulent cholangitis and acute severe pancreatitis, and the consequences are quite serious.

Cancer of gallbladder stones is also a big problem. The risk of cancer in the gallbladder with stones is significantly higher than that of the gallbladder without stones, and the prognosis of gallbladder cancer is very poor, and prevention is critical. Recurrent gallbladder obstruction, biliary colic, and chronic inflammation can also cause chronic fibrosis of the gallbladder, with morphological and functional abnormalities, which in turn further promotes stone progression and forms a vicious circle. Therefore, when there is biliary colic, cholecystitis, abnormal morphology or function of the gallbladder, etc., or there is a high risk of secondary extrahepatic biliary obstruction infection, pancreatitis, and cancer, the patient should undergo surgery in time to remove the gallbladder containing stones and has been diseased.

Gallbladder resection is the most important surgical method for the treatment of symptomatic gallbladder stones, among which laparoscopic gallbladder removal has become the "gold standard" for the current surgical treatment of gallbladder stones due to small damage, rapid recovery, and aesthetic minimal trauma.

Research continues to expand the "list" of gallbladder removal

Although the previous consensus does not advocate preventive gallbladder removal of asymptomatic gallbladder stones, with the deepening of understanding, it has been found that some patients with asymptomatic gallbladder stones do have a very high risk of secondary lesions. For example, small stones are more likely to pass into the extrahepatic bile ducts, triggering obstructive cholangitis and acute severe pancreatitis. Larger in size, longer in duration, with gallbladder stones with polyps, inflammation, wall thickness, calcification, adenosity, and adenosity, has a higher risk of concurrent gallbladder cancer.

Clinically, very few people who suffer from gallbladder stones for a long time without symptoms are rare. Many so-called asymptomatic gallbladder stones patients will have some atypical gastrointestinal symptoms, such as discomfort after a greasy diet, anorexia and greasy, postprandial fullness, epigastric pain, bloating, poor absorption, dyspepsia, etc., but it is not easy to distinguish from other diseases, and it is ignored for failing to establish a definite connection with gallbladder stones. Patients with advanced age, diabetes, and immunocompromised gallbladder stones are more difficult to control with biliary tract infections, and have higher complication rates and mortality rates during emergency surgery.

According to the experience and their own research, different experts and scholars also recommend early gallbladder removal treatment for some special cases of asymptomatic gallbladder stones. The ninth edition of the mainland medical textbook "Surgery" supplements the surgical indications for patients with asymptomatic gallbladder stones: a large number of stones or a maximum diameter of ≥2 cm, calcified or porcelain gallbladder wall, gallbladder polyps ≥ 1 cm, gallbladder wall thickening ≥ 3 mm.

Similar related studies continue to emerge, and the conditions for surgical treatment of patients with asymptomatic gallbladder stones generally include the following: (1) gallbladder function tests finding severe dysfunction or non-functioning of the gallbladder; (2) gallbladder stones with a diameter of more than 2 cm (also said 3 cm, different studies) ;(3) imaging examinations finding porcelain gallbladder; (4) diabetic patients; (5) the elderly, especially those with cardiopulmonary dysfunction; (6) stones with gallbladder polyposis lesions; (7) children's gallbladder stones ;(8) Stones incarcerated in the neck of the gallbladder; (9) family history of cholangiocarcinoma; (10) female patients over 50 years of age with a duration of more than 5 years; (11) atrophy of the gallbladder, dilation of the gallbladder, or significant thickening of the walls of the gallbladder, especially local thickening; (12) patients with immunocompromised or immunodeficient diseases; (13) patients with abnormal duodenal diverticulum or cholangiopancreatic duct convergence near the distal bile duct...

As research progresses, the above content is still increasing. It can be seen that the understanding of the surgical treatment of asymptomatic gallbladder stones is slowly changing, which also reflects the greater emphasis of modern medicine on personalized treatment and precision treatment.

The new Consensus recommendations are more positive and clear

At the end of 2021, the Biliary Surgery Group of the Surgery Branch of the Chinese Medical Association and the Biliary Surgery Committee of the Surgeons Branch of the Chinese Medical Doctor Association updated the original guideline consensus under the guidance of evidence-based medical evidence, and formulated the "Expert Consensus on the Surgical Treatment of Benign Diseases of the Gallbladder (2021 Edition)". The new Consensus emphasizes that cholecystectomy is the only cure for benign gallbladder disease, and that surgical indications include asymptomatic gallbladder stones, i.e., asymptomatic gallbladder stones, and surgical removal of gallbladder is also recommended.

This update of the concept is more based on research on gallbladder stones that explicitly promote gallbladder cancer. Treatment with the removal of gallbladder stones can significantly reduce the incidence of gallbladder cancer. Previous studies have confirmed that the mucosa of the gallbladder can evolve from inflammatory hyperplasia to atypical hyperplasia and subsequent cancerous growth due to long-term stimulation of stones and inflammation. Chronic inflammation leads to local mucosal DNA damage, activates the gallbladder self-repair mechanism, and mucosal cells are in a state of proliferation, thereby accelerating the process of "metaplasia-dysplasia-carcinogenesis" of epithelial cells.

In the early stages of gallbladder cancer, there are many obvious symptoms, the diagnosis rate is low, and most patients are in the advanced stage when they present. The prognosis of advanced gallbladder cancer is poor, with only 10% to 30% of patients having the opportunity for radical resection, and the overall survival rate at 5 years is only about 5%. Multiple studies have shown that patients with gallbladder stones (including asymptomatic patients) have a significantly higher risk of cancer than the general population, especially now that the average life expectancy of the population is getting longer and longer, and the increase in age further increases the risk of cancer. In order to reduce the incidence of gallbladder cancer, even if there are no obvious symptoms, the Consensus recommends that patients with gallbladder stones with risk factors for gallbladder cancer have their gallbladder removed at a later stage.

This important update in the Consensus has sparked lively academic discussions, particularly on how to choose the timing of gallbladder resection, risk prognosis assessment, and methods and methods. The more the truth is argued, the more academic prosperity helps to promote more rational diagnosis and treatment. According to the current medical conditions in the mainland, for a certain period of time, the surgical treatment of asymptomatic gallbladder stones may still need to be considered in combination with local medical resources and patient wishes. For patients who do not undergo surgery, it is recommended to follow up regularly and closely, such as clinical symptoms, related complications, and risk factors for cancer, cholecystectomy must be performed in a timely manner.

(The author is a member of the editorial board of the new edition of consensus.) ）

Author: Zheng Yamin, Professor of General Surgery, Xuanwu Hospital, Capital Medical University

Planner: Fang Tong

Editor: Wang Jianying