Biliary tract infections and cholelithiasis are collective terms for acute and chronic inflammation and calculous lesions of the biliary tract system. The incidence is higher in China’s coastal regions and some southern provinces, making them common and prevalent diseases that pose a threat to public health.
A biliary tract infection refers to a bacterial infection within the biliary tract. While it can occur on its own, it most often coexists with gallstone disease, with the two conditions being interrelated and mutually causative. An infected biliary tract is prone to stone formation, and when gallstones obstruct the biliary tract, 80% to 90% of cases are complicated by infection. Common bacteria associated with biliary tract infections include Escherichia coli, Pseudomonas aeruginosa, Enterobacteriaceae, and anaerobic bacteria.
Gallstone disease includes stones originating in the gallbladder and those originating in the biliary tract system; the two differ significantly in both pathogenesis and clinical course.
I. Factors Contributing to Gallstone Formation
The factors contributing to gallstone formation are highly complex. Over the years, experts and scholars worldwide have conducted extensive research and concluded that the condition is associated with the following factors:
1. Dietary Factors: The formation of gallstones is closely related to a patient’s dietary habits, nutritional status, and metabolic function. Long-term consumption of high-cholesterol foods and diets chronically deficient in essential fatty acids are major risk factors for the formation of cholesterol gallstones in the gallbladder. In Western countries, gallstones primarily occur in the gallbladder. In China, Southeast Asia, and Japan, pigment gallstones originating in the biliary tract were very common before the 1950s. However, in recent years, due to changes in lifestyle and nutritional conditions—including increased consumption of high-cholesterol foods—people who regularly skip breakfast are also prone to developing gallstones. Obesity and lack of exercise lead to increased cholesterol excretion in bile, making it more likely to precipitate and form stones. The author conducted experiments using domestic rabbits. A foreign body (such as a knot of cotton thread, remnants of Ascaris worms, or small human gallstones) was surgically implanted into the gallbladders of the rabbits. This group of rabbits was fed a diet consisting solely of cholesterol. After 3–6 months, the rabbits were euthanized and dissected. It was observed that a layer of cholesterol stones had adhered to the surface of the foreign bodies within the gallbladders, and the livers exhibited fatty liver changes. and the aortic walls of this group exhibited atherosclerosis.
2. The Foreign Body Core Theory: Research conducted at many hospitals in China has revealed that the core of gallstones contains foreign bodies, most commonly parasites—particularly Ascaris remains and Ascaris eggs. Surgeons in the Department of Surgery at Qingdao Municipal Hospital analyzed the autopsies of more than 400 cases of pigment gallstones and found that 78% to 82% of gallstone cores consisted of Ascaris remains. Therefore, it is believed that a foreign-body core is an important factor in the formation of gallstones.
3. Metabolic Disorders: Many experts have observed through clinical statistics that during pregnancy or lactation, women experience accelerated fat synthesis and reduced fat breakdown, leading to elevated cholesterol levels in the body that reach a state of supersaturation. This disrupts the balance between cholesterol, bile salts, and lecithin, causing cholesterol to precipitate and form stones. Additionally, long-term use of estrogen affects the enzymatic system in the liver, reducing bile acid synthesis while simultaneously increasing cholesterol secretion, which can easily induce stone formation.
4. Infectious Obstruction: When the gallbladder and bile ducts are infected with bacteria—particularly Escherichia coli—the composition of bile changes, causing bilirubin to precipitate and combine with calcium ions to form calcium bilirubin stones. Of course, the factors contributing to gallstone formation are multifaceted. The biliary tract system also serves to expel foreign bodies; when roundworms invade the biliary tract, most are expelled. Only a small proportion of patients are unable to expel the roundworms (whether alive or dead); however, once the roundworms die or break down into segmented remnants, they can still be expelled. However, in cases of spasm or edema of the sphincter of Oddi, scarring-induced strictures, inflammatory strictures, or strictures resulting from biliary tract surgery, the ascarid remnants cannot be expelled. Combined with bacterial infection, which causes free bilirubin to precipitate, these pigments then adhere to the ascarid remnants. Each time an infection flares up, the amount of bilirubin precipitation and adhesion increases, and with repeated episodes, the cross-section of the stone may exhibit a “tree ring”-like structural change.
5. Disease and Medication Factors: Certain diseases and medications can elevate blood cholesterol levels, leading to stone formation. For example, patients with diabetes, nephritis, or hypothyroidism have higher blood cholesterol levels than healthy individuals. In clinical practice, the author encountered a woman who was found to have three gallstones the size of soybeans in her gallbladder; however, she had no subjective symptoms and did not undergo treatment. Later, due to hypothyroidism, she began taking thyroxine, and upon re-examination three months later, the gallstones had disappeared. Certain medications, such as Antomin and other lipid-lowering drugs, can stimulate an increase in the excretion of cholesterol in bile, thereby promoting stone formation.
6. Psychological Factors: People who experience prolonged mental stress, feel unhappy or depressed, or are easily irritable—as well as those with irregular eating habits and a lack of exercise—may develop bile stasis and impaired bile flow, which are also risk factors for gallstones.
7. The “Four F” Factors: Numerous studies over the years have shown that people with the “Four F” characteristics are most prone to gallstone disease. The “Four Fs” refer to: Fat (obesity), Female, Fertile (multiple pregnancies), and Forty (age 40). This classification simply indicates that women, obese individuals, and those who have given birth multiple times tend to have higher cholesterol levels in their bodies, making them more prone to gallstone formation; however, it does not mean that only those with the “Four Fs” characteristics will develop gallstones. In my clinical practice, I have encountered many patients with gallstones who are predominantly women in their 20s, not obese, and unmarried; at the same time, I have also seen numerous cases of boys with gallstones, aged only 8 to 13.
In summary, the formation of gallstones involves multiple factors. Internal and external causes, metabolic factors and foreign bodies, infections and obstructions, dietary habits and nutritional components, certain diseases and medications, as well as psychological and physical activity factors all influence gallstone formation; multiple factors may also act simultaneously. According to Traditional Chinese Medicine, emotional distress, exposure to inappropriate temperatures, irregular eating habits, excessive consumption of greasy foods, or parasitic infestations can all lead to stagnation of liver qi. This impairs the descending and regulating functions of the liver and gallbladder, resulting in impaired bile secretion. When the flow is obstructed, pain ensues; prolonged accumulation of damp-heat that fails to dissipate causes bile to coagulate, potentially forming stones.
II. Clinical Manifestations
1. Acute calculous cholecystitis primarily manifests as severe colicky pain in the right upper abdomen. The pain may be persistent or accompanied by paroxysmal exacerbations and may radiate to the right shoulder and back. It is often triggered by a greasy meal and may be accompanied by a fever (above 38°C) during an attack. There is tenderness in the right upper abdomen, abdominal muscle rigidity, and sometimes a palpable, enlarged gallbladder with tenderness.
2. Chronic cholecystitis, particularly when accompanied by small stones, primarily manifests as upper abdominal bloating, belching, aversion to greasy foods, and other symptoms of indigestion. It is often misdiagnosed as a “stomach ailment,” with a disease history ranging from several years to more than a decade. Small gallbladder stones may cause colic and fever due to infection when they dislodge and obstruct the cystic duct—typically after consuming greasy foods or while lying flat at night or on the left side. Approximately 50% of patients with gallbladder stones may remain undiagnosed for life due to the absence of symptoms; these are referred to as silent stones.
3. Common Bile Duct Stones: These typically present as abdominal pain, chills, fever, and jaundice—the classic Charcot triad—accompanied by nausea, vomiting, dark urine, clay-colored stools, and, in severe cases, signs of toxic shock such as a drop in blood pressure. Symptoms of intrahepatic bile duct stones are atypical, often manifesting as recurrent dull, distending pain in the hepatic region and fever, sometimes complicated by jaundice. Ultrasound and CT scans achieve an accuracy rate of over 95% in diagnosing biliary tract stones.
III. Treatment
1. Chronic cholecystitis in the quiescent phase and small gallbladder stones
Body acupuncture points: Riyue, Qimen; auxiliary points: Zusanli, Yanglingquan, Dan Shu.
Auricular acupuncture: Pancreas-Gallbladder, Sympathetic, Shenmen, Liver, Endocrine.
Herbal Medicine: Modified Chaihu Shugan Decoction, administered to soothe the liver, regulate qi, reduce inflammation, and promote bile secretion.
2. Acute Phase of Common Bile Duct Stones: Acupuncture points as above; herbal formula: Bile Duct Stone-Expelling Decoction, used to clear heat, drain dampness, unblock the interior, expel stones, and regulate qi. During stone-expulsion therapy, patients must be closely monitored; if signs of shock appear, active anti-shock measures should be taken, and bile duct drainage surgery should be performed if necessary.
Traditional Chinese Medicine differentiates three patterns:
(1) Qi Stagnation Pattern (Quiet Phase): Dull pain or distension and fullness in the right upper abdomen; no fever or jaundice; thin white tongue coating; string-like and thin pulse. Treatment should focus on regulating qi and relieving depression, soothing the liver and promoting bile flow, using Bile Duct Stone-Expelling Decoction No. 1.
(2) Damp-Heat Type (Acute Phase): Severe pain in the right upper abdomen, chills and fever, jaundice, thick, greasy, yellow tongue coating, and a slippery, rapid pulse. Treatment should focus on clearing heat and eliminating toxins, promoting bile flow and stone expulsion; use Bile Duct Stone-Expelling Decoction No. II. As the condition progresses rapidly, close monitoring is essential.
(3) Toxic Type (Sepsis-Induced Shock): Apathetic expression; cold and clammy extremities; red-crimson tongue with a yellow, dry coating; deep and rapid pulse. Treatment should focus on promoting blood circulation and removing blood stasis, regulating qi, and expelling stones; simultaneously, actively treat shock. If conservative treatment proves ineffective, perform surgical biliary drainage as soon as possible.