Or Gallbladder Have caused severe gallstoneAbdominal pain, Jaundice ,Have a feverDisease symptoms, called"Cholelithiasis". Gallstone disease is the most common Biliary tract Disease.
A common disease in China, in recent years the increasing trend year by year. Was contained by stone composition, divided into three categories: Cholesterol Stone, Bile pigment calculus , mixed stones, of which the most common cholesterol gallstones. According to the site of occurrence of points, can be divided into Gallbladder stones , Extrahepatic bile duct stones And Calculus of intrahepatic duct , gallbladder stones which accounts for about 50- of all stones.
Race and region to northern Europe, North America The country has the highest incidence of gallstone disease, South Africa Area Black The lowest incidence. North American Indians: 25- women with Pima Cholelithiasis . Gallstone components in order to Cholesterol gallstone The most common, accounting for 75- ~ 90-, and the Asia Region is the Bile pigment calculus For many, especially the calculus of intrahepatic duct more domestic in 1985 11342 cases Cholelithiasis Survey showed that: gallstones and bile duct Stone The ratio of 1.5 ∶ 1, cholesterol gallstones and bile pigment calculus in the ratio of 1.4 ∶ 1. Age: 40 years old Cholelithiasis The typical age of onset, less than 20 years old are few, generally increased with age of gallstone disease incidence rate also increased. The autopsy data display Cholelithiasis Detection rate 7-, 80 years old of gallstone disease incidence rate is up to 23-. Female sex Cholelithiasis A male gallstone disease incidence rate is high, the incidence of gallstone disease in women over the age of 50 was 2 times of the male. Most research report showed that, Cholesterol gallstone Patients with positive Family History. Cholelithiasis Risk factors of, Cholesterol gallstone The incidence and the following factors: a lot of monosaccharide are related to diet and high fat diet, the economic total parenteral nutrition conditions of the poor, women, obesity, low high density lipoprotein Cholesterol (HDL-C) Hyperlipidemia , hypertriglyceridemia (TG) in liver cirrhosis, Diabetes mellitus Black, drinking and smoking; Bile pigment calculus And hemolysis, liver cirrhosis, Chronic alcohol poisoning Related; brown Bile pigment Stones and Duodenal diverticulum , Biliary tract infection Relative low protein diet.
Gallstone formation reason has not yet entirely clear, may be a combination of factors of gallstone composition of cholesterol, bile pigment, calcium salt,
The sticky protein and other organic and inorganic matter, according to the stones of different compositions will usually gallstone divided into cholesterol stones, bile pigment stones and mixed stones ( Cholesterol , bile pigment, calcium and other organic inorganic mixed into 3 class). Research over the years has proved, in gallstone is influenced by many kinds of factors, through a series of Pathology Including the physiological process and the formation of these factors Bile The changes of the composition, supersaturated bile or bile cholesterol saturation was too, and single crystalline cholesterol vesicles Precipitation Nucleating factor and anti nucleation factor disorders, gallbladder dysfunction, oxygen free radical participation and biliary bacteria, The parasite Infection.
(1) metabolic factors: bile salt lecithin, cholesterol normal gallbladder bile in proportion to coexist in a stable colloidal clusters in. Normal cholesterol and bile salt ratio is 1 ∶ 20 ～ 1 ∶ 30, such as certain metabolic causes of bile salt lecithin cholesterol, reduce, or increase, when the ratio of less than 1 ∶ 13 the following when cholesterol was precipitated by the formation of large stones, polymerization. Such as Pregnancy Later, the elderly, the cholesterol content in the blood were significantly increased, so many pregnant women and the elderly susceptible; and as the Liver function Impaired bile acid secretion decreased, also easy to form stones. Congenital hemolytic patients, due to a large number of long-term Red blood cell Failure can produce bile pigment calculus.
(2) biliary infection: a large number of literature, from the core of cholelithiasis have developed typhoid bacillus, Streptococcus , Bacillus welchii, Actinomycetes And so on, which shows the bacterial infection plays an important role in stone formation. Bacterial infection In addition to the cause of cholecystitis, the colony, exfoliated epithelial cells can make calculous core, the gallbladder inflammatory exudate Protein Composition, can make calculous bracket.
(3) other: such as bile stasis of bile PH Too low, Vitamin A deficiency, also is one of the reasons for the formation of stones.
(1) secondary to gallstone system some reason gallbladder stones down to the common bile duct, called Secondary choledocholithiasis , occurred in the Calculous cholecystitis Long course of disease, The cystic duct Expansion, stones smaller cases, the incidence was 14-.
2. Primary bile duct stone May and infection of biliary tract, Bile duct stricture , biliary tract The parasite infection (especially Ascaris lumbricoides Infection related). When the infection of biliary tract, Escherichia coli producing beta glucuronidase activity is very high, can be in bile Conjugated bilirubin The latter are hydrolyzed into free bilirubin and bile Calcium ion Combined into calcium bilirubin is not soluble in water after precipitation of bile pigment stones become. Biliary ascariasis The secondary infection of biliary tract, more prone to this kind of stone, this is due to ascariasis Residues Eggs, cuticle and subsequently into the bacteria, inflammatory products can make calculous core. Bile duct stricture Is bound to affect the bile flow is smooth, resulting in cholestasis bile pigment and cholesterol are more likely to precipitate the formation of stones. When the merge Chronic inflammation When the stone formation, then the process more quickly. In short, biliary tract infection, obstruction in the formation of stones in the reciprocal causation, mutual promotion.
In 1, gallbladder stones in early often has no symptoms, most are found in regular physical examination. Sometimes may be associated with slight discomfort was mistakenly believed to be stomach trouble without timely treatment.
The 2 part, single or multiple gallbladder stones, freedom exists in the gallbladder, not easy to embed, rarely cause symptoms, known as asymptomatic cholecystolithiasis.
In 3, gallbladder stones can be inlaid in the neck of the gallbladder, cause clinical symptoms, especially in eating oily food after gallbladder contraction, or sleep due to postural changes, can aggravate symptoms.
4, when the stone is embedded in the neck of the gallbladder, causing acute obstruction, leading to increased pressure within the gallbladder, bile can not be discharged through the gallbladder neck and cystic duct, which cause clinical symptoms, usually for biliary colic. A persistent right upper abdominal pain, paroxysmal aggravation, right shoulder back radiation, often accompanied by nausea, vomiting. Some patients may be in a few hours after the clinical symptoms relieved.
5, if the gallbladder stones do not alleviate continuously, the gallbladder will continue to increase, even with infection, and progression to acute cholecystitis, if not promptly treated, some patients can progress to acute suppurative cholecystitis, gallbladder perforation can be serious, serious clinical after fruit.
Gallstone formation is very complex, some factors, can not be changed. For example: increasing age, female, racial, genetic and family history; some are acquired factors, some can be reversed, for example: pregnancy, Obesity , low fiber, high calorie diet structure, long time of fasting, certain drugs such as ceftriaxone, lipid-lowering drugs, oral contraceptives, rapid weight loss (>1.5kg/wk), metabolic syndrome, special disease etc..
Age of onset: gallstone incidence is increased with age. If in childhood onset, associated with hemolysis or congenital biliary disease. The peak age of onset in 40 ~ 50 years old.
Gender differences: the ratio of male and female incidence study of ultrasonic diagnosis was 1 ∶ 2, female gallstone with multiple cholesterol gallstones, cholesterol gallstones in women with estrogen can increase the cholesterol in bile secretion, reduce the total bile acid and active, and Progesterone Effect of gallbladder contraction, resulting in cholestasis related.
In the racial differences between incidence and gene, family history of gallstone disease significantly, suggesting that genetic factor is one of the pathogenesis of gallstone disease.
Can promote the formation of gallstones in patients with pregnancy on pregnancy, and the number of pregnancy and the incidence of gall stones were positively related to. Because of pregnancy estrogen increased bile composition changes, could increase bile cholesterol saturation and pregnancy period; gallbladder emptying slowly; the changes of body weight and diet during pregnancy and postpartum also influence bile composition, changes the enterohepatic circulation of bile acid, promoted the formation of cholesterol crystallization.
The incidence of obesity in clinical and epidemiological studies show, obesity is an important risk factor for obesity and cholesterol gallstone, the incidence of normal weight people 3 times.
With the onset of dietary factors, eating habits are the main factors influencing the incidence of gallstone formation, eating low fiber, high card food gallstone was significantly higher. Because this kind of food increase bile cholesterol saturation. In China, with the improvement of living standards, the pathogenesis of gallstones has occupied the main status of gallstone disease, with cholesterol gallstone.
The basic factors of gallstone formation are: changing 3 often more than 2 kinds of pathogenic factors combined bile physicochemical properties of physical and chemical changes of bile, bile stasis and infection of the bile pigment or cholesterol precipitation, the formation of stones; bile stasis can make too much moisture is absorbed in the bile, bile excessive concentration, increase bile pigment concentration, cholesterol supersaturation, can promote gallstone formation; Bacteria Infection may result in biliary inflammatory edema Cells Fiber hyperplasia infiltration and chronic phase lead to biliary wall thickening, stenosis or closed
Plug, causing bile stasis. Inflammation exudate cells or epithelial, bacteria. Residues And eggs can also be used as the core of calculi, promote gallstone formation.
(1) the formation mechanism of cholesterol calculus in bile cholesterol content: such as excessive saturation was too, is easy to precipitate formation Cholesterol gallstone (such as the long-term consumption of high fat diet). Bile and bile salt concentration in normal Lecithin Can and cholesterol Protein A mixture of colloidal particles in suspension composition of bile without precipitation. In some intestinal diseases due to precipitation loss of bile salt stimulated cholesterol, stone formation.
(2) the formation mechanism of bilirubin calculus: free bilirubin concentration in bile increased can be combined with calcium in bile, formation of insoluble calcium bilirubinate and precipitation. Bilirubin and glucuronic acid in normal bile combined into esters and free. Glucuronidase in intestinal bacteria Escherichia coli, is the decomposition of the esters that bilirubin free role so there is a bacterial infection of the intestines, Intestine Ascariasis of biliary tract inflammation and easy formation of bilirubin. In addition, increased bile pigment content (such as excessive red blood cell destruction), calcium in bile and bile increased acidity can promote the formation of such stones.
(1) cholesterol stones: stones were the main components of cholesterol were oval (single) or polyhedral (multiple), surface smooth or slightly Tubercle Like yellow or yellowish white, soft soft, section radially lineate, X-ray Plain film of the stones in the undeveloped Gallbladder Inside, often as a single, large volume, diameter of up to a few centimeters. Such stones in China for less than Europe and the United States, the incidence of cholelithiasis does not exceed about 20-.
(2) bile pigment stone: stone composition with calcium bilirubinate, may contain a small amount of cholesterol. For silt like soft and brittle, and some such as round as some sand into brown or red brown, unequal in size. Because of low calcium, X-ray plain film is not developing. The sand like the size of 1 ~ 10mm, often for many, many in the liver, bile duct.
(3) mixed stones: composed of cholesterol, bile pigment and Calcium salt More than 2 types of main component is formed at intervals. The shape is not a, for polyhedral particles surface is smooth, rounded edge, a dark green or brown, section is layered like tree trunks or ring or ring radially by calcareous more, on X-ray plain film sometimes developing (called positive stones). In the gallbladder, are visible in a bold pipe size, unequal, often multiple, general 20 ~ 30. In order to Bilirubin Mixed gallstone based in China, the most common, accounting for about 90- of cases of cholelithiasis above.
① gallstone types: mixed pigment sediment stones than cholesterol stones
② the incidence of bile duct parts: more than gallbladder, intrahepatic bile duct stones have a higher incidence of
The Pathogeny: previous statistics Biliary ascariasis Play an important role in gallstone formation. In recent years, due to health and nutrition level of diets improve has changed.
1. Acute cholecystitis The severe epigastric or right upper quadrant Angina , radiating to the right shoulder back, even can induce Angina pectoris , it can have different degrees of heat, and often have nausea, vomiting, abdominal distension and loss of appetite. The different degrees of jaundice.
2. Acute suppurative cholangitis : abdominal pain, Shiver , fever and jaundice Common bile duct stones And Acute cholangitis Typical performance.
(1) chronic non calculous cholecystitis and its clinical manifestation is not typical, as right upper quadrant or epigastric varying degrees of pain or tingling, eating Greasy food Or exertional symptoms.
2. Chronic calculous cholecystitis Many repeated attacks or angina pectoris, every autumn to attack more frequently. The larger stones sometimes asymptomatic long-term.
3. Chronic cholangitis And Calculus of bile duct The clinical manifestation is not typical, can not have a symptom or similar Chronic cholecystitis Sign.
In general, the gallstone formation in different parts of biliary tract, the symptoms are not exactly the same. According to gallstones, bile duct stones and intrahepatic bile duct calculus to describe their clinical manifestations
(1) biliary colic or upper abdominal pain: Biliary colic Is a visceral pain mostly because of cystic duct stones have been temporary obstruction. If with acute inflammation of the gallbladder coexist, the gallbladder wall can have different degrees of congestion, edema and thickening pathology. In typical cases, patients often have recurrent upper abdominal pain, often located in the right upper quadrant or upper abdomen, they behave as colic pain may be exacerbated by eating; in some cases the pain can be in the night. Angina occurred in the lack of Physical activity Or lack of exercise (such as long-term bed). Typical of biliary colic episodes were gradually increased in 15min or 1H, and then decreased gradually; about 1/3 of patients with sudden onset of pain may be a minority of patients the pain suddenly
However, termination. If the pain continues for 5 ~ 6h or more, often suggestive of acute cholecystitis. About half of the patients pain often radiation to the right scapular area District, central or right shoulder back. Biliary colic attack patients often agonizing. The pain Intermittent episodes can be a few days, weeks, months or even years, in the attack on time cannot forecast Biliary colic A characteristic.
(2) nausea and vomiting: most of the patients with biliary colic accompanied with nausea and vomiting, heavy with cold sweat. Vomiting after biliary colic often relieved to some extent. The duration of vomiting is generally not very long.
3. Indigestion : dyspepsia for Fat And other food intolerance, often manifested as excessive Belching Or expansion of the abdomen, postprandial fullness early satiety Heartburn Wait for a symptom. Dyspeptic symptoms may occur with gallstone and there exists or Cholecystitis And other relevant.
(4), chills and fever: when complicated with acute cholecystitis, patients may have chills, fever; when Hydrops of gallbladder The formation of gallbladder empyema or secondary bacterial infection Gangrene , perforation, the chills, fever is more significant
Jaundice (5): simple gallbladder stone does not cause jaundice only when accompanied by common bile duct stones (or inflammation Cholangitis ), jaundice part with skin pruritus or gallbladder stones into the common bile duct caused obstruction.
(6) the right epigastric tenderness: some simple cholecystolithiasis patients in physical examination right upper quadrant abdominal tenderness may be present. Such as acute cholecystitis, right upper quadrant abdominal tenderness muscle tension, which can sometimes be palpable gallbladder, positive Murphy sign.
7. Gallbladder heart syndrome : cardiac dysfunction or heart rhythm changes caused by gallstone and biliary disease reflex, in a group of clinical syndrome known as gallbladder heart syndrome, and patients with coronary heart no Implement qualitative sex pathological change Cholelithiasis caused Coronary heart disease Mechanisms like symptoms due to cholelithiasis biliary obstruction, bile duct pressure increased, the Spinal cord Nerve reflex (disposable, gallbladder and heart in 4 ~ 5 thoracic spinal nerve Spinal nerve Crossing the visceral -) Splanchnic nerve Reflex pathway, cause The coronary vessels Systolic blood flow reducing weight can cause Myocardial hypoxia And the occurrence of angina pectoris, Arrhythmia Or ECG changes etc..
Calculus of extrahepatic bile duct stones in the common hepatic duct means and the common bile duct, is the most common bile duct stones, about 15- of the Gallbladder stones The patient can coexist with common bile duct stones, and increased with age, increased the proportion of two. On the other hand, common bile duct stones in about 95% of patients with coexisting with gallbladder stones and common bile duct stones were located in the common bile duct stones at the lower end and The duodenum Ampulla. When the gallstone obstruction of common bile duct can produce the typical symptoms and signs. Increased pressure is the main clinical manifestations and biliary obstruction, bile duct, Biliary excretion Blocked and bile concurrent bacterial infection is closely related to such factors as the typical symptoms Biliary colic , Shiver , high fever and jaundice, triple called choledocholithiasis syndrome, or charc
(1) abdominal pain or cramps: common bile duct stones in more than 90- of the patients had abdominal or right upper abdominal pain or cramps, radiating to the right shoulder back. Cause of angina is impacted stones in the common bile duct ampulla, obstruction of common bile duct and stimulates sphincter of Oddi and bile duct Smooth muscle Induced colic can be in after eating greasy food induced, or change of posture, the body bumps induced. Even with the cold sweat pale, nausea and vomiting.
2. Shiver And High fever : common bile duct stones in about 75- of patients with biliary colic in attack, due to complicated with bile duct Bacterial infection Chills and fever caused by, Body temperature Up to 40 ℃. Cause chills, fever is the infection to spread retrograde hepatic, pathogens and toxins by Hepatic sinusoid , Hepatic vein To The body circulation Due to Systemic infection Results a few common bile duct stones, such as acute biliary obstruction with acute suppurative inflammation caused by infection of severe biliary duct, is called acute suppurative cholangitis or severe Acute cholangitis There may be Hypotension , toxic shock and Septicemia The clinical manifestations of systemic poisoning.
Jaundice (3): common bile duct stone were about 70-, in the abdominal cramps, fever after 12 ~ 24h to mechanism of jaundice jaundice is caused by impacted stones in the ampulla of Vater can't loose, bile duct obstruction caused by not ease, often accompanied by itching urine is a thick brown Faeces Color pale or clay colored the majority of patients with jaundice is wave, can be eased in the 1 weeks, due to dilatation of bile duct stones eased after the relaxation of the sphincter or calculi and into the duodenum. Some scholars believe that the jaundice was intermittent appearance or performance too deep and shallow is the characteristic of common bile duct stones.
(4): physical examination in abdominal tenderness Xiphoid And right upper quadrant have deep tenderness, inflammation or often accompanied by abdominal muscle insecurity liver area can have percussion pain. Such as smooth cystic duct, and sometimes can also be palpable. Gallbladder .
Calculus of primary hepatic duct bifurcation part, called the calculus of intrahepatic duct. Stones can be widely distributed in the hepatic biliary system, also can be scattered in a branch of intrahepatic bile duct inside, also can happen in a hepatic lobe or segment of the bile duct. A large number of data show that, stones occurred in the left intrahepatic bile ducts were found. The main clinical manifestations:
(1) abdominal pain: calculus of intrahepatic duct atypical symptoms scattered in small stones in intrahepatic bile duct usually does not cause symptoms or persistent right upper abdominal and chest back only Pain Or dull pain. Generally do not occur angina.
(2) jaundice: bile duct stone general liver is not jaundice, only when the bilateral or the left, the right lobe of the bile duct were stone blocking occurs when the majority of jaundice, may be associated with biliary colic or more intense pain. Such as concurrent infection of biliary tract, also can appear Shiver And High fever Also, even for the development of acute suppurative cholangitis.
(3) abdominal tenderness: physical examination often involves enlargement Liver And tenderness, a few may have liver area percussion pain. Most of the data showed that, calculus of intrahepatic duct and common bile duct stones coexist, so when the typical symptoms of patients with cholelithiasis (cramps, chills and fever, Jaundice ) is often the symptoms of common bile duct stones.
The most serious complication of acute cholecystitis cholelithiasis is different severity, including gangrene, emphysematous cholecystitis, gallbladder abscess and perforation. Chronic calculous cholecystitis Is the common complication of gallbladder stones. In addition, gallstone pancreatitis complication and, Liver abscess , Cholangitis Uplink, hepatitis, portal vein thrombosis, Mirizzi syndrome And Carcinoma of the gallbladder Etc.. In addition to chronic cholecystitis (cholecystolithiasis patients are associated with almost every chronic cholecystitis gallstone patients), about 20- of the complications, and along with the age growth, a significant increase in the incidence of complications
Mirizzi syndrome is a rare complication of cholelithiasis. It is impacted gallstone in the gallbladder neck and cystic duct hepatic duct and common hepatic duct pressure caused by a group of symptoms stenosis. Inlaid in the The three tube The confluence of gallstone, called a confluent calculus (Figure 1) diagnosis Mirizzi syndrome 3 key points: gallbladder stones in neck of gallbladder calculus; oppression and stone inlay itself induced inflammation at the site of fibrosis leads to some mechanical obstruction of recurrent hepatic duct; Cholangitis Or cause cholangitis cirrhosis due to obstruction. The clinical symptoms mainly right upper abdominal pain, jaundice and fever Cholangitis Performance. Mirizzi syndrome And the confluence stones are not developing in gallbladder angiography (whether oral or intravenous), the positive rate of B ultrasound and CT in diagnosis of neck of gallbladder calculus is low, it is often dependent on the PTC and ERCP directly Cholangiography Diagnosis. Dietrich considered that only the existence of possible cystic duct and common hepatic duct was abnormal anatomy of parallel time Mirizzi syndrome . But most scholars believe that is not the case. Mirizzi syndrome The operation treatment is often difficult, often stay after operation Bile duct stricture And fistula formation and other sequelae.
The common complications of bile duct stones with different degrees Cholangitis Bacterial infection and bile duct. Secondly, for gallstone pancreatitis, Liver abscess Biliary fistula, septicemia and gallstone Intestinal obstruction Etc.. Due to gallstone compression lead to bile duct Mucosa Ulcer, causing bile duct stricture is rare in China sometimes visible due to gallstone compression caused by bile duct mucosa ulcer, necrosis and hemorrhage, and Western countries Common bile duct stones were rare, Hemobilia In addition, the long-term repeated seizures induced by common bile duct stones Cholangitis And jaundice can further develop into biliary Cirrhosis .
Mainly on the basis of cholelithiasis clinical manifestations, laboratory and Imaging Findings and diagnosis.
(1) biliary ascariasis: simple biliary ascariasis in adolescent presented with sudden onset of subxiphoid angina or a drilling pain, a few patients with knee chest position when the pain can be alleviated, the pain is often paroxysmal remission and ordinary people can have no symptoms. The majority of patients with vomiting and even vomiting bile have vomiting Ascaris person. Pain exacerbation of symptoms are very heavy, but the abdomen often lack signs this is characteristic of biliary ascariasis as B ultrasound examination, sometimes in the bile duct can be found in the insect body image. Generally speaking, according to the characteristics of pain and B-mode ultrasonography Inspection, the diagnosis rate reaches above 90-.
(2) acute The pancreas Arthritis: pain often in Gluttony After induced, pain is persistent abdominal pain, sometimes a knife like pain often left waist radiation, a beam with dragging pain. Patients with blood, Urine amylase Often significantly increased; B type ultrasonic examination showed diffuse or localized pancreatic enlargement; CT or MRI examination can also be found in pancreatic enlargement has important value on diagnosis. If the patient appears Shock , Abdominal puncture Take courage and uprightness Ascites The amylase content, increased significantly, it can be diagnosed as Acute hemorrhagic necrotizing pancreatitis . It must be pointed out, sometimes common bile duct stones can cause acute Pancreatitis (called Biliary pancreatitis At this time), the symptoms can be confused reason should be vigilant.
3. Peptic ulcer Perforation: upper abdominal pain and rapidly throughout the whole abdominal, physical examination revealed abdominal muscle board like rigidity and tenderness Rebound tenderness The liver dullness, shrink or disappear. X-ray plain film can be found or subdiaphrgmatic air. Combined with the previous Ulcer History is not difficult to determine the diagnosis.
(4) angina pectoris or Acute myocardial infarction : a handful of angina or acute myocardial infarction patients can be manifested as abdominal subcostal pain, and pain to the left and right upper quadrant abdominal radiation, which often restless, cold sweat, fear or Feeling of impending death . ECG Examination can be found to change deep and wide Q wave, ST segment and T wave inversion. Serum creatine phosphokinase (CPK), Aspartate aminotransferase (AST), Lactate dehydrogenase (LDH) and Troponin Myoglobin, higher in the diagnosis of great help.
(5) the other diseases: cholelithiasis needs and acute intestinal obstruction, acute Volvulus , Intestinal perforation , acute Appendicitis Perforation, acute superior mesenteric artery embolism or Thrombosis Ectopic pregnancy, women and Torsion of ovarian cyst Such pain disease phase identification.
(1) acute Viruses B: loss of appetite, fatigue and Low heat Wait for prodrome. Jaundice appears quickly, gradually, reaching a peak in 1 ~ 2 weeks, with liver enlargement and tenderness. B ultrasound examination can eliminate obstructive jaundice Ultrasonography Show only slightly increased liver, hepatic parenchymal echo enhanced Intensive General signs. Serum enzyme. Often ALT, AST significantly increased. Most patients can detect virus markers of hepatitis.
2. Carcinoma of head of pancreas : pancreatic head cancer in male, age of onset is generally larger. Jaundice was deepening, upper abdominal pain and the pain position, supine position, and leaned forward can reduce or alleviate pain. Duodenography showed duodenal flexure enlargement, shift and gastrointestinal signs of compression. B ultrasound, endoscopic retrograde cholangiopancreatography (ERCP) and CT or MRI examination can be found in pancreatic head mass.
(3) the ampulla of Vater carcinoma: Huang Danchang as the first symptom, progressive deepening. Gastrointestinal Barium meal Hypotonic angiography, Gastroscope Or duodenoscopy, B ultrasound, CT or MRI examination can be found ampullary masses are very helpful for diagnosis. Endoscopy combined with biopsy can be made Pathological diagnosis .
(4) the other diseases: cholelithiasis and bile duct carcinoma is needed, Primary carcinoma of the liver Transfer to Hepatic portal Lymph nodes (enlarged lymph nodes can be oppressive bile duct and jaundice), jaundice disease phase identification.
1 when the gallstone bilirubin metabolism of bile duct obstruction, Serum Total bilirubin, which is combined with bilirubin 1min bilirubin and total bilirubin is often greater than 40-; such as complete obstruction of bile duct, the ratio may be greater than 60-. In urine Bilirubin Content increased significantly, while the Urobilinogen Decreased or absent, Stercobilinogen Also reduce or disappear.
2 serological enzyme examination of obstructive jaundice Alkaline phosphatase (ALP) significantly increased, often more than 3 times the normal value; Gamma glutamyl transpeptidase (γ -GT) were significantly increased in serum; Transaminase (ALT, AST) were mild to moderately elevated; lactate dehydrogenase (LDH) is generally slightly higher.
Determination of bile duct obstruction 3 prothrombin time, prothrombin time, prothrombin time application of vitamin K could be recovered to normal. But such as bile duct obstruction caused by long-term liver function damage, even if the injection Vitamin K prothrombin time will not return to normal, suggesting that thrombin original disorder of liver cell manufacturing.
Determination of ratio of normal human serum iron and serum copper 4 serum iron and copper content of 0.8 ~ 1, when biliary obstruction, increase the serum copper content, make the iron copper ratio less than 0.5.
5 duodenal drainage has been less used, is the main drainage fluid collection more trouble, and not for the majority of patients accepted. The collection of duodenal fluid in two ways, namely the duodenal intubation and endoscopic retrograde cholangiography for. Generally required in the application of eight peptide cholecystokinin stimulated gallbladder contraction, duodenal fluid to collect rich in bile and then this liquid in a Microscope Under microscope, such as the discovery of Cholesterol crystal And (or) are important to help the bile pigment calcium salt particles on the diagnosis of cholelithiasis.
1 X-ray plain film of abdomen, Oral cholecystography X-ray and intravenous cholangiography traditional flat, oral cholecystography and intravenous cholangiography inspection method in recent years has been less used
(1) mixed stone calcium on X-ray plain film may be developing and simple Cholesterol Gallstones and bile pigment calculus on X-ray plain film can not be developed; gallbladder stones in 10- ~ 20- for calcium Positive Stones can display 80- ~ 90- as negative stone in abdominal plain film, plain film can not see, contrast to display.
(2) oral cholecystography gallbladder developing rate is very high, can reach more than 80-, it can be found in the gallbladder, and even have no bile duct calculi. But because the development is affected by many factors, the accuracy rate of the diagnosis of gallbladder stone is only 50- ~ 60-.
(3) intravenous cholangiography may understand the hepatobiliary bile duct has no existing calculi and obstruction, bile duct dilatation at all levels have no. Due to intravenous cholangiography is influenced by many factors, so its accuracy is not very high, only about 50-.
2 of endoscopic retrograde cholangiography (ERCP) and endoscopic retrograde cholangiography by duodenoscopy after The duodenum Papillary intubation, injection of contrast agent, display Biliary system A high diagnostic method and the pancreatic duct of cholelithiasis value. After angiography can clearly display the bile duct and gallbladder bile duct and gallbladder can therefore be found without stones, bile duct without expansion or stenosis and changes of ERCP in the diagnosis of choledocholithiasis positive rate of up to 95%. If the bile duct stenosis, obstruction factors, it can only display the following biliary obstruction of the image, and the obstruction of bile duct stones with no more than often cannot display, at this time should be combined with the PTC and other examination methods to further clarify the diagnosis
3 percutaneous transhepatic cholangiography (PTC) and percutaneous transhepatic cholangiography for unknown causes of obstructive jaundice, suspected Biliary calculi Stenosis and other bile duct diseases. In the X-ray TV or B ultrasound guided percutaneous puncture of bile duct, the success rate is up to 80- ~ 100%. PTC can clearly show the liver and biliary system, can provide the biliary anatomy, pathological changes, the correct scope and nature, are helpful in the diagnosis and differential diagnosis of the disease. The positive rate of PTC in the diagnosis of choledocholithiasis was about 90-. Because PTC is a damage detection, so it has certain complications such as bleeding, bile leakage or infection occurred Cholangitis Etc..
4.CT or MRI examination by B type ultrasonic examination failed to detect lesions could be used in CT or MRI check the CT calculus sensitivity to calcium is very high, often can display 2mm diameter small stones, 80- ～ accuracy can reach CT diagnosis of gallstone in 90-. Plain You can display the amount of calcium stones of intrahepatic bile duct common hepatic duct, common bile duct and gallbladder high; by oral or intravenous contrast agent, CT Can display the bile pigment stones and mixed stones, also can display the sediment samples of gallbladder stones. CT of pure cholesterol stones sometimes easy leak diagnosis. In recent years, MRI technology has been gradually used in the clinical diagnosis of gallstone diagnostic accuracy rate is very high because the CT or MRI Check the cost is expensive it is generally not as the preferred method of inspection
5 intraoperative cholangiography in preoperative biliary disease not clear diagnosis, the method is to add a wonderful, method is simple and safe. Intraoperative transcystic common bile duct intubation or direct puncture, injection of contrast agent 30ml 20- concentration of 15- ～, can obtain biliary imaging more clear. Binding was found, will be able to fully understand the hepatobiliary conditions conducive to diagnosis and treatment can reduce biliary residual stone rate units should be conditional to carry out the inspection.
Check the ultrasonic examination ultrasonic 6.B is convenient to check, repeated, noninvasive diagnostic accuracy advantages, has become the preferred method for diagnosis of cholelithiasis. Whether cholecystolithiasis, Extrahepatic bile duct stones Or intrahepatic bile duct stone, in B ultrasound sonogram, calculi showed echo enhancement of light or spot behind it is often accompanied by acoustic shadow. Gallstone typical performance is as follows:
(1) the gallbladder one or more intense Echoes The light regiment.
(2) echo with the change of posture and movement patients.
(3) in the Strong echo The light regiment of the rear sound clear shadow.
Stones in the common bile duct as affected by The gastrointestinal tract Gas interference, often difficult to display, therefore, B ultrasound in diagnosis of common bile duct stones of low accuracy, but also can appear false positive or false negative. Because of the different structure, composition and location of gallbladder stones, there may be some atypical manifestation. Such as the gallbladder bile filled with stones, due to the lack of background, the image is not clear and the Acoustic shadow Loose stones can not appear typical acoustic shadow, atrophy of gallbladder with stones can cause substantial echo then acoustic shadow is not clear in general, the correct rate of up to 95% to B ultrasound diagnosis of gallbladder stones in 97-, the correct rate of diagnosis of common bile duct stones was 53- ~ 84-, the correct rate of intrahepatic bile duct stone 80- ~ 90- especially. X-ray Stone and B ultrasound in gallbladder is not developing can make correct diagnosis in the ultrasonic manifestation is not typical, still should be verified with X-ray and CT scan, diagnosis.
Cholelithiasis treatment aims to alleviate the symptoms, reduce relapse remove stones, avoiding the occurrence of complications. Should first non operation treatment in acute stage of attack, the symptom control, further examination, a clear diagnosis; such as a serious condition, non operation treatment is invalid, should be timely operation treatment based on the preliminary diagnosis.
The main indications for primary attack: young patients with non operation treatment; quickly alleviate the symptoms; clinical symptoms are not typical; disease for more than 3 days, no emergency operation indications and symptoms in non operation treatment of regression. Commonly used non Operation therapy : mainly includes bed rest, fasting or Low fat diet , infusion, correcting water electrolyte and Disturbance of acid-base balance Anti infection, spasmolysis acetanilide and symptomatic treatment. Yes Shock Should strengthen the anti Shock Treatment, such as absorbing Oxygen , maintain blood volume, using the boosting drugs in time etc.. After the treatment, can be relieved, the acute phase after 4 ~ 6 weeks Zaihang deterministic biliary operation, can make the patients from again Operation Pain.
(1) the control diet: fatty foods can promote cholecystokinin (cholecystokinin) caused by the release of the contraction of the gallbladder, promote the secretion of bile, row so, in order to be able to make the gallbladder and the biliary gets proper rest should be fasting fatty foods in the acute phase, but with high sugar juice diet. Foods rich in cholesterol, such as brain, liver, kidney, eggs, egg yolk, whether in cholelithiasis exacerbation or stationary phase were less food is appropriate. Without obstruction of the common bile duct stones or in stationary phase, vegetable oils have choleretic effect is not limited.
(2) pain relief: mild pain can be controlled by diet, rest, anal exhaust treatment and relief of symptoms, severe cases except fasting, should be inserted nasogastric tube Gastrointestinal decompression To suck, gastric and duodenal contents, gas, reduce gastric and duodenal contents on bile secretion stimulation, is conducive to the drainage and discharge also can eliminate or reduce the effect of cholecystokinin gallbladder contraction induced by bile, thus reducing the biliary colic attack frequency and reduce the degree of pain. In addition to the application of spasmolytic Painkiller And sedatives.
1. Nitroglycerin : every time 0.3 ~ 0.6mg3 ~ 4H in sublingual 1 times. Can also be used long time action of nitric acid ester of controlled-release agent
② Atropine 0.5mg: every time the subcutaneous or intramuscular injection, every 3 ~ 4 hours of intramuscular injection of 1 times; or (654-2) 20mg anisodamine intravenous drip of 250ml of 10- glucose, 1 ~ 2 times /d.
③ analgesic: Pethidine (dolantin) or bucinnazine (AP-237) 50 ~ 100mg Intramuscular injection , better
The analgesic and antispasmodic drugs, can enhance the analgesic effect. But the morphine can induce Oddi Physiological sphincter Spasm The taboo. Some people think that biliary colic and local prostaglandin release, which can be of indomethacin ( Indomethacin Treatment
(3) the cholagogic and anti infection treatment: Magnesium sulfate oral have relaxed Oddi Physiological sphincter The role of the residence, the bile is easy to discharge, oral administration of 50- Magnesium sulfate 10 ~ 15ml3 /d, on postprandial oral (severe diarrhea should not use); bile salt stimulated Liver A thin bile secretion, conducive to washing biliary tract, for symptomatic relief period and for several weeks, can reduce the recurrence of symptoms; Dehydrocholic Acid Tablets 0.25g or cholic acid tablets 0.2g, 3 times /d, the meal to take these 2 kinds of medicine is not easy to use in biliary obstruction of biliary tract, to avoid increasing the pressure in the acute bacterial with infection of patients with cholelithiasis, appropriate use of antibiotics is necessary. Antibiotics should be considered in the selection of its antimicrobial spectrum, drug concentration in bile and its adverse reaction, often using broad-spectrum Antibiotics , especially against gram negative bacilli sensitive antibiotic and anti Anaerobic bacteria Drugs (e.g. Metronidazole And so on), in accordance with the best Bacterial culture Results to choose if the types of bacterial infection is unclear, the priority should be selected in the bile in the highest concentration of antibiotics when necessary to strengthen the antibiotics, the use of Hormone The treatment, in order to reduce the Inflammatory reaction To enhance the stress ability of body,
(4) in treatment of chronic cases: the choleretic agents such as deoxycholic acid, Sodium taurocholate (sodium deoxycholate) Xiaoyanlidan tablet , hydroxymethylnicotinamide (Bilocid), with music, also pay attention to diet, can control seizures. Reports in the literature: the DNA chenodeoxycholic acid (CDCA) and ursodeoxycholic acid (UDCA) for dissolving treatment, can cause partial gallbladder stones to shrink or disappear, but long time administration (usually takes six months to 1 and a half years), a large number of applications can damage the liver, after stopping the medicine stones and relapse, the proper case can try.
(5) the acupuncture therapy of traditional Chinese medicine: it has been reported in acute biliary disease cure rate reached 88.2-. The main points for Gallbladder point , Yang Lingquan , Zusanli , supplemented by liver yu, Danshu Traditional Chinese medicine; plus, through syndrome differentiation with Shugan Qi, cholagogue analgesia or Clearing heat and removing dampness , Tongli Gongxia (commonly used drugs Bupleurum Root, pinellia tuber, Mu Xiang Gold, jade, Akebia, gardenia, bacteria such as Chen Dahuang). Eased through the treatment of the majority of cases symptoms. The traditional Chinese medicine in the treatment of chronic patients is particularly suitable, but Biliary calculus Decoction Or pig's trotters with ear acupuncture, Paishi therapy on calculous Gallbladder Inflammatory effect, and can cause acute suppurative cholangitis, constrictive duodenal papillitis, it should not be used on Calculus of bile duct Researchers lithagogue treatment is certain, common bile duct stone soup. The main drugs are Lysimachia christinae 30g, Costus root 9g Fructus aurantii 9g 9g of Radix Scutellariae, rhubarb 6G, addition and subtraction with the disease: High fever , jaundice, poisoning symptoms or Jia Yinchen, honeysuckle, gardenia, gentian, bupleurum; Chest tightness Abdominal pain, abdominal distension, serious and peony, toosendanin, corydalis tuber, Magnolia officinalis So researchers used dried tangerine peel, Amomum villosum; anorexia, Gallus gallus , Jiao Shanzha, the Divine Comedy, fried malt; such as nausea and vomiting and ginger, pinellia, Zhu Ru; fierce abdominal pains and mirabilite. General /d 1 agent, cent is taken 2 times; such as Shi "offensive" therapy for 1 day, 2 to 3 times a week, 4 ~ 6 times as a course of 1, as appropriate, for 4 ~ 6 courses. The principle is: to serve biliary calculus decoction, the bile is secreted increase re injection Morphine Or neostigmine, the sphincter of Oddi (so called close), causing bile retention, bile duct pressure, 40min after administration of amyl nitrite, Magnesium sulfate, plus acupuncture needle electrode plate treatment, the sphincter of Oddi (the so-called open door), gallbladder contraction, a large amount of bile, at the same time bile duct stone has been discharged. This method is adapted to the:
Calculus of common bile duct diameter less than 1cm
② hepatobiliary "sediment" like stone.
The liver is widely small stones, can not be removed by operation or remove obstruction after there is still residual stones.
The symptom is light, the larger stones without severe complications.
The operation before and after discharge to reduce biliary stones Inflammation In order to facilitate the operation and prevent stone recurrence.
The other serious diseases are not suitable for operation treatment. But the main Bile duct stricture Or proximal to the stricture calculi, can not use the non operation treatment should closely observe the patient's condition, such as disease progression, toxic shock, should seasonable operation cure.
(6) other treatment: cholelithiasis acute exacerbation with biliary obstruction, can appear icteric and Skin itching Jaundice, control the pruritus induced by available Calamine Lotion scrub, or application to dihydroergotoxine (hydrogen ergot amine) 1mg. Also can consider to use energy and bile acid binding Cation exchange resin Cholestyramine ( Cholestyramine ) and liver enzyme inducers such as rifampin, such as phenobarbital. Antihistamines can also relieve itching, but the effect is not ideal. It is worth mentioning that, cholestyramine (cholestyramine) in obstructive jaundice. No treatment effect; in addition, the long-term use of cholestyramine (cholestyramine) should pay attention to vitamin AD, K etc. Fat soluble vitamin And calcium salt. The recent report the application of opioid receptor antagonist, naloxone and 5-HT3 receptor antagonist, ondansetron, antipruritic effect, but little experience
(7) after percutaneous transhepatic biliary drainage ( PTD ): on bile duct obstruction or purulent Cholangitis PTD operation, feasible, with drainage of the bile duct, biliary tract infection control, reduce the pressure to reduce The mortality rate Operation time, win.
(8) under endoscopy The duodenum Incision of the nipple (EPT): this method is suitable for common bile duct calculi diameter <3cm, papillary stenosis confirmed by ERCP with Bile duct dilatation , cholestasis. Postoperative self row of stone or stone instrument removed stone also can be placed in the common bile duct drainage tube for biliary - long nasal drainage.
Extracorporeal shock wave lithotripsy (9): this method for cholecystolithiasis effect is poor, although the stone but not necessarily row net, still have a recurrence of stones, and has some complications, expensive. Bile duct stones can try.
Drug Rongshi therapy include oral dissolving drug therapy and local injection of soluble drug treatment.
(1) oral dissolving drug treatment: oral dissolving drug in the treatment of cholelithiasis, with intake of cholic acid in The small intestine In the full absorption and the acid can increase cholesterol dissolution based, so only the cholesterol stones of bile pigment stones and calcium containing stones are invalid. Cholesterol is the maximum solubility of 200µ in water; g/L, the existence of the best in the bile acid and lecithin condition, the solubility of cholesterol is 20 ~ 40g/L50 molecule acid dissolved 1 molecules of cholesterol chenodeoxycholic acid (chenodesoxycholic, acid, CDCA) and Ursodeoxycholic acid (ursodeoxycholic acid, UDCA) concentration could increase in bile acid and secondary to reduce the secretion of cholesterol in the liver; Chenodeoxycholic acid (CDCA) can reduce cholesterol synthesis, and UDCA can reduce the absorption of cholesterol, can also induce the formation of cholesterol and lecithin micelles in the stone surface, accelerate the stones Dissolution . Chenodeoxycholic acid (CDCA) and ursodeoxycholic acid (UDCA) solution mechanism of stone table 1 comparison. Chenodeoxycholic acid (CDCA) used alone stone dissolving rate is relatively low, ranging from 20- to 40-, to take 6 to 9 months, relapse after discontinuation rate of 50- long-term medication approximately 1/4 of patients Hepatitis Diarrhea and Hyperlipidemia And other adverse reactions. The proposed therapeutic dose for non obese 12 ~ 15mg/ (kg · d) and obese due to cholesterol content of bile duct increased to 18 ~ 20mg/ (kg · D). Ursodeoxycholic acid (UDCA) stone dissolving effect than chenodeoxycholic acid (CDCA), and the side effect is small, but the more expensive price, its treatment is recommended dose of 8 ~ 10mg/ (kg · D); Obesity Researchers need to increase the dose because of chenodeoxycholic acid (CDCA) and ursodeoxycholic acid (UDCA) dissolve gallstone role differences, people found that the combination of stone dissolving effect than either agent alone can improve the efficiency of 50-, to reduce adverse reactions, easy to accept the patient. Combined treatment with the recommended dose chenodeoxycholic acid (CDCA) 6 ～ 8mg/ (kg · d), ursodeoxycholic acid (UDCA) 5mg/ (kg · d), treatment 1 ~ 2 years, the effective rate was 50- ~ 90-. Such as the continuous treatment for 9 months, still no obvious litholytic effect, often hint the stone is not easy to dissolve. The combined with calcium stones heavier patients Enteritis Should not be used before suffering from liver disease or diabetes.
(2) percutaneous, transhepatic gallbladder catheter drug dissolving directly: percutaneous transhepatic gallbladder catheter and endoscopic nasal biliary catheter placement, and gallstone contact, injection of Rongshi treatment agent dissolved stone.
Dissolution Cholesterol gallstone Drug:
A. single Xin fat (monooctanoin, MO): is a semi synthetic vegetable oil, locally injected MO 5 days litholytic effect, the drug adverse reaction occurred in 60- patients, severe abdominal pain, diarrhea, nausea and vomiting Serum alkaline phosphatase Increased etc.. The medicine has a viscosity, the equipment needed to make into the drug infusion pump infusion with gallbladder stones in full contact.
B. methyl tert butyl ether (methyl tert-butyl ether, MTBE): treatment for cholesterol gallstones, especially not suitable for open operation or laparoscopic cholecystectomy patients, drug injection to 1 ~ 5 days began litholytic effect. The main adverse reactions were abdominal pain, nausea, vomiting blood vessel Hemolytic reaction (drug may enter the blood vessels), and even the emergence of Acute renal failure So, if MFBE is injected into the hepatic parenchyma error can lead to necrosis of liver cells
The drug solution bile pigment calculus: including two methyl sulfoxide amine (DM50), egtazic acid sodium (Na-EDTA), six methyl sodium phosphate (Na-HMP), limonene, ethyl thioglycollic acid and so on in vitro certain litholytic effect of these drugs have, but because the contact litholytic effect is not ideal and there are certain side effects limit its clinical application.
The rapid development of 3 endoscopic sphincterotomy in recent years the endoscopic treatment, such as endoscopic sphincterotomy (stone with air bag or basket), basketball lithotripsy via mouth Choledochoscope Treatment of direct laser electrohydraulic and high-frequency current stone of bile duct stones have achieved good results, so that the operation should be done in patients suffering from operation to operation especially do not or cannot tolerate operation patients, provides
The prognosis :
1 gallstones are still treated mainly by operation, non operation therapy such as extracorporeal shock wave lithotripsy, stone dissolving, although has certain curative effect, but the long course of treatment, many side effects, the effect is not exact.
2 endoscopic stone extraction: endoscopic duodenal papilla distal common bile duct opening together with partial sphincter incision, into the stone basket or balloon catheter stone, large stones into stone crushing device (minced) after removing the stone, the success rate of more than 90-, but also cut out the blood of acute gastroduodenal perforation Pancreatitis Biliary tract infection, complications, the incidence of 1- ~ 6-.
Gallbladder stones Primary prevention Mainly in the following 2 aspects: ① the supersaturation of cholesterol and bile formation of gallstones in concentration, so the control of dietary cholesterol intake is an important means to maintain the bile to maintain a certain stability. In daily life, the reasonable adjustment Dietary structure Fatty foods, eat less cholesterol more, eat rich Gao Danbai Food, Vegetables And fresh Fruits Pregnant women should cause enough attention. In addition to appropriate physical exercise, in order to prevent the excessive accumulation of fat in the body. The annual regular physical examination, including hepatobiliary B ultrasound examination, to facilitate early detection, early treatment.
Intrahepatic bile duct stone is mainly aimed at the secondary intrahepatic bile duct stone, Extrahepatic bile duct stones And biliary ascariasis is the main cause of intrahepatic bile duct stone. Therefore, calculus of intrahepatic duct Primary prevention Mainly in the following two aspects: ① active treatment Extrahepatic bile duct stones While preventing the occurrence of intrahepatic bile duct stones, definite diagnosis as soon as possible after operation of choledochal exploration, take net calculi, smooth Bile At the same time, the early application of sensitive drainage Antibiotics , the active and effective control of infection of biliary tract. Bile drainage and control infection of biliary tract is important in the prevention of intrahepatic bile duct stone. The prevention and treatment of biliary ascariasis of biliary tract roundworm disease of liver Calculus of bile duct The important causes of its prevention and treatment, can not be ignored.
Diet styleShould be light, less slag, easily digestible diet,
Condiment of choiceAvoid eating can cause abdominal Flatulence Food with strong spices, sharp contraction in case of gallbladder caused by acute attack.
Edible oilThe diet should be mainly due to vegetable oil, vegetable oil have a certain choleretic effect.
Cooking methodSteamed, boiled, stewed with mainly appropriate diet, food to eat too much fried, cold, great irritation.
Be careful to eat.Due to the formation of gallstones and bile due to alcohol content is high, so the animal offal, roe, egg yolk, liver and kidney, fat should strictly control and constraint.
Eat more fruits and vegetablesUsually advised to eat more vitamin rich fruits and vegetables. Ginger class has to promote Cholesterol metabolism Role, can often eat.
Obese patients attentionThe amount of limiting sugars and high sugar content of food intake, in order to facilitate the synthesis of reduced fat.
Gallbladder stone and Gallbladder polyps The difference in the image is obvious, the ultrasonic image of typical performance is as follows:
The gallbladder appeared stable morphology Strong echo The light regiment. The ultrasonic often show crescent, half moon shaped or spherical (image above like eclipse, because ultrasound can not penetrate the stone formation, sonographic only back in the stone surface and reflection)
The trailing edge with acoustic shadow stone. Ultrasonic back in reflective stone surface, stone formation at the trailing edge vacancy area of ultrasonic wave, so the trailing edge stone light group appeared in a long strip shaped echo free area, called stone posterior acoustic shadow.
When the turning of the body, along with the posture of gallbladder stones to lower direction, namely image visible light group with position moves to the direction of gravity.
Gallbladder polyps of gallbladder wall: a spherical local hypoechoic in moderate echogenic mass to the gallbladder is prominent, often with pedicle. Position fixed, not with the body moving.