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Diabetes
People with diabetes generally have high levels of fatty acids called triglycerides. These fatty acids may increase the risk of gallstones. Gallbladder function is impaired in the presence of diabetic neuropathy, and regulation of hyperglycaemia with insulin seems to raise the lithogenic index. A lack of melatonin could significantly contribute to gallbladder stones, as melatonin inhibits cholesterol secretion from the gallbladder, enhances the conversion of cholesterol to bile, and is an antioxidant, which is able to reduce oxidative stress to the gallbladder.
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For practical purpose gallbladder disease can be equated with gallstones as these are present in the large majority of patients. Most patients with gallstones have no symptoms. These gallstones are called ¡Èsilent stones¡É and may not require treatment. ÃÀÀоɤÎÎ×¾²ÀâÌÀ
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¿¤¯¤Î¾ì¹ç¡¢ÆÃ¤Ë»éËä¬Â¿¤¤¿©»ö¤Î¸å¤Ëȯºî¤¬µ¯¤³¤ê¡¢¤Û¤È¤ó¤É¾ï¤ËÌë´Ö¤Ëµ¯¤³¤ê¤Þ¤¹¡£ Some patients with gallstones present with acute cholecystitis, and often secondary infection by intestinal microorganisms, predominantly Escherichia coli and Bacteroides species. Inflammation of the gallbladder wall causes severe abdominal pain, especially in the right upper quadrant, with nausea, vomiting, fever, and leucocytosis. This condition may remit temporarily without surgery, but it sometimes progresses to gangrene and perforation. Less commonly, gallstones can become lodged in the common bile duct (choledocholithiasis), sometimes with obstruction of the common bile duct and symptoms of cholestasis. Obstruction leading to jaundice though commonly caused by a stone migrating into the common bile duct, can be due to compression of the common hepatic duct by a stone in the neck of the gall bladder or cystic duct (Mirrizi syndrome). Infection in the bile ducts (cholangitis) can occur even with a seemingly minor degree of obstruction to bile flow. Stones in the common bile duct usually cause pain in the epigastrium or right upper quadrant, but may be painless. The passage of common-bile-duct stones can provoke acute pancreatitis, probably by transiently obstructing the main pancreatic duct where it passes near the common bile duct at the ampulla of Vater. Gallstones may fistulate directly into the duodenum from the gallbladder during a period of silent inflammation. This stone can impact in the duodenum leading to duodenal obstruction (Bouveret's syndrome) Alternatively, gallstones can impact at the narrowest portion of healthy small, bowel causing an obstruction termed gallstone ileus.
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The Diagnosis of Gallstone Disease
This disorder is usually diagnosed by history of recurrent episodes of right-upper-quadrant or epigastric pain, suggesting biliary colic and Boas¡Ç sign. There may be fever, tender right upper quadrant with or without Murphy's sign, tenderness when the hand taps the right costal arch (Ortner's sign). ÃÀÀоɤοÇÃÇ
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The three primary methods used to diagnose gallbladder disease are ultrasonography, nuclear scanning (cholescintigraphy), and oral cholecystography. Today, ultrasonography is the method most often used to detect cholelithiasis and cholecystitis. Occasionally gallstones are diagnosed during plain X-rays. Ultrasonography has a specificity and sensitivity of 90-95%, and can detect stones as small as 2 mm in diameter. It can demonstrate the presence of common-bile-duct stones, show bile-duct dilatation and detect thickening of the gallbladder wall.¡ÊÃæÎ¬¡Ë
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Treatment
Treatment of gallstones depends partly on whether they are causing symptoms or not. Recurrent episodes of upper abdominal pain related to gallstones are the most common indication for the treatment of gallstones.Delaying elective cholecystectomy until repeated episodes of pain occur results in a minimal decrease in life expectancy. ½èÃÖ
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Prophylactic cholecystectomy was recommended for diabetic patients with gallstones because of an increased risk of acute cholecystitis and increased mortality with emergency cholecystectomy. Recent studies show that diabetic patients have increased operative risk with elective as well as emergency gallbladder surgery related to risk of cardiovascular disease and other coexisting conditions rather than to diabetes mellitus itself. Most authorities do not recommend cholecystectomy in diabetic patients without symptoms of gallstones.
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°ìÈÌŪ¤ÊÃÀ´É·ëÀФ¬Ê¢¹Ð¶À²¼ÃÀǹŦ½Ð½Ñ¤Î´Ö¤ËÃÀ´É¤±Æ¤Ë¤è¤Ã¤ÆÍ½´ü¤»¤ºÈ¯¸«¤µ¤ì¤¿¾ì¹ç¡¢°ìÈÌŪ¤ÊÃÀ´É¤Î³«ÊüŪ¤Êõº÷¤¬É¬ÍפȤʤ뤳¤È¤¬¤¢¤ê¤Þ¤¹¡£ The laparoscopic procedure requires more operating time than the open procedure, but usually only one night in the hospital postoperatively; postoperative pain is greatly reduced, and the patients can usually return to work early, i.e., in one to 2 weeks, as compared with 4-6 weeks after open cholecystectomy.
Ê¢¹Ð¶À¼ê½Ñ¤Ï³«Ê¢¼ê½Ñ¤è¤ê¤â¿¤¯¤Î¼ê½Ñ»þ´Ö¤òɬÍפȤ¹¤ë¤¬¡¢¼ê½Ñ¸å¤Ë¤ÏÄ̾ï1Ìë¤Î¤ß¤Ç¤¹¡£ ½Ñ¸åáÖÄˤÏÂçÉý¤Ë·Ú¸º¤µ¤ì¡¢³«Ê¢ÃÀǹŦ½Ð¸å¤Î4~6½µ´Ö¤ÈÈæ³Ó¤·¤Æ¡¢´µ¼Ô¤ÏÄ̾ïÁá´ü¤Ë¡¢¤¹¤Ê¤ï¤Á1~2½µ´Ö¤Ç»Å»ö¤ËÌá¤ë¤³¤È¤¬¤Ç¤¤Þ¤¹¡£ Attempts to use oral bile salts to dissolve gallstones began more than 30 years ago because of those who refuse or are poor risks for surgery. Chenodeoxycholic acid (chenodiol) and ursodeoxycholic acid (ursodiol) are known to dissolve gallstones, but chenodiol causes diarrhoea and abnormal aminotransferase levels, while ursodiol does not. Therapy with bile salts is suitable for only a minority of patients with symptomatic cholesterol gallstones. It is not suitable for patients with acute cholecystitis or stones in the common bile duct, who need urgent action. Candidates for treatment with bile salts should have a patent cystic duct and noncalcified cholesterol gallstones. Gallstones frequently recur after oral bile salts are stopped.
ÃÀÀФòÍϲò¤¹¤ë¤¿¤á¤Ë·Ð¸ýÃÀ½Á»À±ö¤ò»ÈÍѤ·¤è¤¦¤È¤¹¤ë»î¤ß¤Ï¡¢¼ê½Ñ¤òµñÈݤ¹¤ë¤«¡¢¤Þ¤¿¤Ï¼ê½Ñ¤Î¥ê¥¹¥¯¤¬Ä㤤¤¿¤á¡¢30ǯ°Ê¾åÁ°¤Ë»Ï¤Þ¤ê¤Þ¤·¤¿¡£ ¥±¥Î¥Ç¥ª¥¥·¥³¡¼¥ë»À¡Ê¥±¥Î¥¸¥ª¡¼¥ë¡Ë¤È¥¦¥ë¥½¥Ç¥ª¥¥·¥³¡¼¥ë»À¡Ê¥¦¥ë¥½¥¸¥ª¡¼¥ë¡Ë¤ÏÃÀÀФòÍϲò¤¹¤ë¤³¤È¤¬ÃΤé¤ì¤Æ¤¤¤Þ¤¹¤¬¡¢¥±¥Î¥¸¥ª¡¼¥ë¤Ï²¼Î¡¤È°Û¾ï¤Ê¥¢¥ß¥Î¥È¥é¥ó¥¹¥Õ¥§¥é¡¼¥¼¥ì¥Ù¥ë¤ò°ú¤µ¯¤³¤·¤Þ¤¹¤¬¡¢¥¦¥ë¥½¥¸¥ª¡¼¥ë¤Ï¤½¤¦¤Ç¤Ï¤¢¤ê¤Þ¤»¤ó¡£
ÃÀ½Á»À±ö¤Ë¤è¤ë¼£ÎŤϡ¢¾É¸õÀ¥³¥ì¥¹¥Æ¥í¡¼¥ëÃÀÀдµ¼Ô¤Î¤Û¤ó¤Î¾¯¿ô¤ËŬ¤·¤Æ¤¤¤Þ¤¹¡£ µÞÀÃÀǹ±ê¤Î´µ¼Ô¤ä¶ÛµÞ¤Î½èÃÖ¤¬É¬ÍפʰìÈÌŪ¤ÊÃÀ´É¤ÎÀФˤÏŬ¤·¤Æ¤¤¤Þ¤»¤ó¡£
ÃÀ½Á»À±ö¤Ç¼£ÎŤ¹¤ë¸õÊä¼Ô¤È¤Ï¡¢ÃÀǹ´É¤ÈÈóÀг¥²½¥³¥ì¥¹¥Æ¥í¡¼¥ëÃÀÀФξì¹ç¤Ç¤¹¡£ ·Ð¸ýÃÀ½Á»À±ö¤ò»ß¤á¤¿¸å¤ËÃÀÀФ¬ÉÑÈˤ˺ÆÈ¯¤·¤Þ¤¹¡£ Contact dissolution therapy of cholesterol gallstones rapidly is possible by instilling solvents like the organic solvent methyl tert-butyl ether into the gallbladder through a percutaneous catheter placed through the liver.Alternatively, a nasobiliary catheter can be endoscopically guided into the gallbladder can be used for instilling the organic solvent. This is a technically difficult and hazardous procedure, and should be performed only by experienced doctors in hospitals where research on this treatment is being done. Serious side effects include severe burning pain.
Finally a mixture of plant terpenes may also be useful for dissolving radiolucent gallstones, particularly when used in combination with a bile acid. ¥³¥ì¥¹¥Æ¥í¡¼¥ëÃÀÀФÎÀÜ¿¨ÍϽÐÎÅË¡¤Ï¡¢Íµ¡ÍÏÇÞ¥á¥Á¥ëtert-¥Ö¥Á¥ë¥¨¡¼¥Æ¥ë¤Î¤è¤¦¤ÊÍÏÇÞ¤ò¡¢´Î¡¤òÄ̤äÆÇÛÃÖ¤µ¤ì¤¿·ÐÈéŪ¥«¥Æ¡¼¥Æ¥ë¤ò²ð¤·¤ÆÃÀǹ¤ËÃíÆþ¤¹¤ë¤³¤È¤Ë¤è¤Ã¤Æ¿×®¤Ë²Äǽ¤Ç¤¹¡£ ¤¢¤ë¤¤¤Ï¡¢É¡¹ÐÆâ¥«¥Æ¡¼¥Æ¥ë¤òÃÀǹ¤ËÆâ»ë¶ÀŪ¤ËͶƳ¤¹¤ë¤³¤È¤¬¤Ç¤¡¢Íµ¡ÍϺޤòÃíÆþ¤¹¤ë¤¿¤á¤Ë»ÈÍѤ¹¤ë¤³¤È¤¬¤Ç¤¤Þ¤¹¡£
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