What is laparoscope?

Laparoscopy is a microsurgery that has no need of incision in the abdomen performed by using special instruments and special laser surgical electric technology such as laparoscopy with a special camera attached, video monitoring. Compared to existing surgical methods, this surgical method has the advantage of no big scar left and no interference at daily life.


Laparoscopy Center

Cholelithiasis(GB Stone)

01 Outline

What is cholelithiasis?

Gallstones(GB stone) means the occurrence of a small, gravel-like substance inside the gallbladder.

A gallbladder(cystis fellea) is formed in a small sac-shaped structure, it is located on the upper right side of the abdomen which is under the liver. Cholelithiasis is a disease that makes the fluids stored in the gallbladder hardened into a rock-like substance that is called the gallstone. In western countries 10% of the total population, and in South Korea 4% of the population suffers from gallstones.

This liquid called ‘bile’ is needed to support the digestion of fat, it is first produced in the liver then stored in the gallbladder until the body needs it. When needed, the gallbladder contracts and pushes out the bile to a tube named the common bile duct. As the bile moves to the end of the common bile duct which is connected to the small intestine, the bile is finally excreted to support the food digestion.

Structure of liver/bile duct/pancreas

About 500 ~ 1,200 ml (average of 800 ml) of bile is produced in a day. Bile contains water, cholesterol, fat, bile salt, protein and bilirubin. Bile salt inside the bile resolves fat and bilirubin makes the bile and stool show a yellowish-brown color. But if the liquid bile contains too much of a cholesterol, bile salt, bilirubin it may harden into a gallstone.

Different type of cholelithiasis depending on the anatomical localization

According to the anatomical locations, a gallstone is sorted into two, ‘gallbladder stone’ and ‘gallbladder stone at the biliary tract’. And the gallbladder stone at the biliary tract is once again divided into two, ‘intrahepatic bile duct gallstone’ and ‘extrahepatic bile duct gallstone’. If sorted by a chemical composition, it is divided as cholesterol gallstones and pigment gallstones.

80% of all gallstones are cholesterol stones, that usually have yellow-green color and are mainly made of hardened cholesterol. And for pigment gallstone, it is a small black stone made of bilirubin. The size of the gallstone may be as small as a grain of sand, but also be big as a golf ball. There may be a single large gallstone, or a hundreds of tiny gallstones, or it may occur in the combination of these two types of gallstones stated previously, developed in the gallbladder.

If any of the gallstone that has slipped out of the gallbladder, blocks the tube that carries the bile starting from the liver to the small intestine, it may cause a blockage in the normal flow of the bile. These are some of the tubes that the bile goes through

  • Ductus hepatocysticus : A passage that carries the bile out from the liver
  • Cystic duct : Carries the bile within and without the gallbladder
  • Common bile duct : Carries the bile starting from the cystic duct and ductus hepatocysticus, to the small intestine

When the bile is jammed in these tubes, it may lead to inflammation on the gallbladder, bile ducts and in a rare case the liver. Including the pancreatic duct that carries the digestive enzymes from the pancreas, various tubes are connected to the common bile duct. In some cases the gallstone that has passed down through the common bile duct may cause inflammation on the pancreas. This situation is referred as gallstone pancreatitis. It may lead to serious pain and potential dangerous conditions.

If any of the bile ducts are blocked for a certain time, it causes serious damage and infection to the gallbladder, liver, pancreas. By any chance left without getting medical treatment, it may lead to fatal situations. We usually diagnose the degree of the situation’s seriousness by these symptoms: fever, jaundice, constant pain.

  • * 작성 및 감수 : 대한의학회 / 간담췌외과학회
  • * 출처 : 국가건강정보포털
02 Causes


Cholesterol gallstones occur in these situations : the bile containing too much cholesterol and bilirubin, bile containing insufficient amount of bile salt, when the gallbladder cannot fully release or sufficiently excrete produce the bile. But sadly, the accurate cause of these imbalance hasn’t been discovered yet.

Also the cause of pigmented gallstones are yet to be found too. Pigmented gallstones tend to occur on patients with these characteristics: cirrhosis on the liver, infection on the bile duct, hereditary blood disorders such as drepanocytic anemia that causes the liver to produce massive amount of bilirubin.

Risk factor

As for risk factors, the simple existence of gallstones may cause more of them to develop. The factors that influence the development of cholesterol gallstones in particular include these factors:

- Sex

The occurrence rate of cholelithiasis in women patients are about twice as high in men patients. Extreme estrogen because of pregnancy, hormonal imbalance caused by hormone replacement therapy, oral contraceptives makes the cholesterol levels inside the bile increase and reduces the movement of the gallbladder resulting cholelithiasis.

- Family medical history

Cholelithiasis tend to show high occurrence in families, this shows the possibility of genetic association.

- Overweight and rapid weight loss

As obesity is one of the major risk factor of cholelithiasis, cholelithiasis is particularly common in obese women patients. Results in huge clinical studies also shows that overweight too increases the risk of cholelithiasis.

If you’ve been fasting for a long-term or have experienced sudden weight loss, the body metabolizes fat. This makes the liver to make additional cholesterol secretion by the bile, causing the production of gallstone. It also interferes the gallbladder's proper excretion of the bile.

- Diet

A diet full of high-fat, high-cholesterol, and low-fiber increases the risk of cholelithiasis development by causing the increase of cholesterol levels in the bile and reducing the bile excretion from the gallbladder.

- Age

Patients over 60s, are more likely to get gallstones. It is because as humans age, they tend to secrete more cholesterol in the bile than usual.

- Cholesterol decrease drugs

Drugs that lower cholesterol levels in the blood actually Increases the amount of cholesterol excreted in bile. By this, the risk of cholelithiasis increases.

- Diabetes

Usually diabetes patients have high levels of fatty acids called the neutral fat. This may increase the risk of cholelithiasis.

There is a thing called as ‘4F’ in the cholesterol gallstone correlated factor, this is referred as Female, patient with age over Forties, Fatty, Fertile. As cholesterol gallstone has high occurrence in women than men, patients over 40 years old, obese patient, and patient with multi-parity, we call this four factors as 4F.
Patients with high risk of cholelithiasis are.

  • Women, especially if she’s pregnant or dosing on an oral contraceptive pill and estrogen replacement drug.
  • Patients over 60 years old.
  • Patient that is obese or over-weighted
  • Patients that has been fasting or experienced sudden massive weight loss.
  • Patient with family medical history of cholelithiasis
  • * 작성 및 감수 : 대한의학회 / 간담췌외과학회
  • * 출처 : 국가건강정보포털
03 Symptoms


The symptoms of cholelithiasis varies from no symptoms at all to stomachache, jaundice, fever. Most common symptoms from above is stomachaches and stomach cramp.

As the gallstone moves along the bile duct, it tends to cause bile duct obstruction. When this happens, the pressure inside the gallbladder increases and results in on or more symptom occurrence. The symptoms caused by blockage of the bile duct is usually called a gallbladder attack, since it happens very suddenly. Gallbladder attacks tends to appear especially after a greasy meal and during the night time. A typical gallbladder attack may cause these kind of symptoms.

If you are experiencing these kind of gallbladder attacks, go visit the hospital. These symptoms tend to occur while the gallstones move along the biliary tract. Symptoms of gallbladder attack may improve temporarily, but can also lead to bile duct obstruction. This causes infection on the gallbladder which could make the gallbladder burst.

If you are experiencing any of the symptoms stated below, you need a medical treatment from the doctor.

  • Pain that lasts for 5hours
  • Nausea and vomiting
  • Mild or severe fever and chills
  • When the skin and the white of the eye seems yellowish(jaundice)
  • Gray soft stool

Although many patients have gallstones, not much do they have particular symptoms. This is referred as “asymptomatic gallstone”. These gallstones does not interfere with the functions of the gall, liver, pancreas and does not need a medical treatment. As for the case of asymptomatic gallstone, 50% of the patients live along their lives with no particular abnormal symptoms.

  • * 작성 및 감수 : 대한의학회 / 간담췌외과학회
  • * 출처 : 국가건강정보포털
04 Diagnosis

Abdominal ultrasound exam

Cholelithiasis may be discovered while cholecystitis diagnose, but sometimes are accidentally discovered during another examinations. If a patient is suspected of cholelithiasis, we proceed an abdominal ultrasonography. Although it diagnoses more than 90% of the gallbladder gallstones, it lacks in accuracy when it comes to intrahepatic gallstones or gallstones in the bile duct.

Abdominal ultrasonography usually makes the gallstones appear white, and since it cannot pass through gallstones because of the characteristics of ultrasound, creates a dark shadow behind the gallstones. Unlike other lesions like gallbladder polyps and etc, gallstones inside the gallbladder could actually move when the patient changes one’s posture. So you may be requested to change your posture or to do breathing exercises during the examination.

Computed tomography(CT)

CT(Computed tomography) is a non-invasive radiography that makes the cross-sectional images of the human body. This test not only shows the gallstones, but also the complications of it such as infection of the gallbladder or bile duct, and perforation.

Magnetic resonance cholangio-pancreatography(MRCP)

Endoscopic retrograde cholangio pancreatography is used to diagnose and treat gallstone in the bile duct by detecting the location and removing them. Procedure : It is performed under mild anesthesia, makes the endoscope pass the throat and go through the stomach until they reach the small intestine. As the endoscope is connected to a computer, video monitor, the doctor adjusts the endoscope and obtains visual data by injecting a contrast agent in order to make the bile duct more visible at the monitor. This method helps the doctor to see the location of gallstones and bile ducts with disorders, the discovered gallstones are also removed by the devices equipped on the endoscope.

Cholescintigraphy(HIDA Scan)

Cholescintigraphy obtains a visual data of the gallbladder by injecting a harmless amount of radioactive material to the patient. The principles of this procedure is, when this radioactive material is absorbed into the gallbladder, it stimulates the gallbladder to contract. This test is used to diagnose abnormal contractions of the gallbladder and obstruction of the bile duct.

Other examinations

In order to detect signs of infection, obstruction, pancreatitis, jaundice, a blood test may be proceeded.

Symptoms of cholelithiasis are : heart attack(angina), appendicitis(cecitis), stomach ulcer, irritable colon syndrome, diaphragmatic hernia, pancreatitis, hepatitis(since cholelithiasis has similar symptoms with it, accurate diagnosis is crucial).

  • * 작성 및 감수 : 대한의학회 / 간담췌외과학회
  • * 출처 : 국가건강정보포털
05 Treatment


If the incident discover of asymptomatic cholelithiasis occurred, no treatment is required. But if you’ve experienced particular symptoms because of cholelithiasis, you may consider undergoing cholecystectomy. Since the gallbladder is not an essential organ for human survival, the surgery that removes the gallbladder is one of the most common surgeries performed in adults patients.

It is still a controversial issue whether the patient needs cholecystectomy or not, when diagnosed with asymptomatic gallstone. But in the following cases, we recommend cholecystectomy to the patient.

  • Patient with high risk or has suspension of gallbladder cancer
  • Patients with calcification of the walls in the gallbladder or porcelain gallbladder
  • Patients with gallbladder polyp bigger than 1cm accompanied with gallstone
  • Patients with gallstones bigger than 3cm
  • Patients with adenomyoma at the gallbladder accompanied with thickening on the gallbladder walls.
  • Although the patient has gallstone on the common bile duct, but are experiencing no particular symptoms
  • Patients planing on an organ transplant
  • Patients with hemoclastic conditions that makes chronic blood cell break such as sickle-cell anemia

Not every patient needs cholecystotomy, but some patients show high chances of symptom occurrence in the future. So some actually consider going through surgery for the benefit of prevention purposes.

  • Patients with life expectancy over 20 years has high chance of symptom occurrence in the future
  • Patients with gallstone bigger than 2cm
  • Diabetes patients
  • Patients who have shown dysfunction on the gallbladder in gallbladder function examination
  • Patients with gallstones, experiencing indigestion with no apparent cause.

The treatment depends on the location of the gallstones, it differs whether the gallstones are in the gallbladde, the liver or the extrahepatic biliary tract. Additionally the existence of symptoms and the composition of gallstones may affect the treatment plan. Also the removal method of the gallstones varies from surgically opening the stomach, to taking lithotriptic medicine, and finally removing the gallstone by endoscopy.

Surgical treatment

Almost every cholecystectomy is done by laparoscopically. After the anesthetic is injected, the doctor creates some small holes in the abdomen in order to put a laparoscope and a small video camera thought it. Then the camera inside the abdominal cavity sends an enlarged visual data to the video monitor. Now the doctor is ready to observe a close-up view of the organs and tissues. While watching the visual data, using the devices, the doctor carefully separates the gallbladder from the liver, bile ducts and other structures. Then cuts the cystic duct and removes the gallbladder through one of the small holes priorly made on the abdomen.

Usually one night of hospitalization is enough for the recovery after laparoscopic cholecystectomy. The patient may resume normal activities at home after resting for a few days. Since the laparoscopic surgery does not cut the abdominal muscle layer, it has less pain andcomplications compared to laparotomy which needs 10-20cm of incision in the abdomen.

But if a severe inflammation of the gallbladder shows during the screening which means that the gallbladder was infected or you’ve experienced injury by any other surgeries, you might have to receive a laparotomy. Some patients goes through laparotomy when the doctor discovers some problems during the laparoscopic operation, and needs a bigger incision site than now. To recover from a laparotomy, it may take 3-5 days of hospitalization and weeks staying home. Laparotomy takes about 5% of the total gallbladder surgery.

The most common complications of gallbladder surgery are damage on the bile ducts. Damage on the bile duct may lead to bile leakage to the damaged common bile duct, cause pain, and also has the possibilities of dangerous infections occuring. Small damages could sometimes be treated by non-surgical treatments, but for the case of a big damage, it has a bit more serious condition and may require additional surgery.

Endoscopic treatment

If the gallstones are existing inside of the bile duct, the location of the gallstones may be found by retrograde cholangio pancreatography before or during the gallbladder surgery and removed through endoscopy at the same time. Some of the patients who have received cholecystectomy may get diagnosed in gallstones in the bile ducts after weeks, months, or even years after the surgery. In this cases, the gallstone is successfully removed by endoscopic retrograde cholangio pancreatography and endoscopic cholelithotomy.

Oral dissolution of gallstone

For drug treatment in treating gallstones, the Ursodiol(brand of the name: Urusa) a component derived from bile acids are medicated. We give this treatment a try when the gallstone’s main component are cholesterol gallstones, the patient only have mild symptoms like digestive disorders or epigastric discomfort, the sized of the gallstone is less than 1.0cm. There may be some side effects such as mild diarrhea, abdominal pain, and biliousness.

Direct gallstone dissolution

This experimental medical treatment skills are proceeded by directly injecting the medication into the gallbladder to dissolve cholesterol gallstones. Although this may dissolve a few of the gallstones within a few days, it is also reported that it leads to irritation and complications. It is a skill usually considered in patients that has small gallstones accompanied with symptoms.

Complication treatment of cholelithiasis

- Acute cholecystitis

About 10% of the patients with symptomatic cholelithiasis experience acute cholecystitis. It is caused by the complete obstruction on the cystic duct. If the acute cholecystitis is late-diagnosed, it may lead to gangrenous cholecystitis, gallbladder perforation, biliary peritonitis. So the diagnosis of the acute cholecystitis should be proceeded through clinical suspicion and diagnostic imaging(a high-sensitivity test such as ultrasonography and gallbladder scintigraphy).

In the past, early surgery for acute cholecystitis was not recommended that much. Because of that, many patients received treatment with jugular vein IV, antibiotics, pain killers until the inflammation of the gallbladder was healed. Then selectively considered on undergoing cholecystectomy(late-cholecystectomy). But sadly, more than 20% of patients shown no response from this medical treatment or experienced recurrence of cholecystitis during the treatment. Studies that compared early cholecystectomy with late-cholecystectomy, about whether the early cholecystectomy could improve the treatment outcome of acute cholecystitis, has shown that early cholecystectomy could shorten the total hospitalization period than the late-cholecystectomy but could not reduce the overall complication rate. Based on these study results, when diagnosed as acute cholecystitis a patient should receive treatment with jugular vein IVs and undergo cholecystectomy as early as possible while solving the accompanied medical problems.

If the patient with acute cholecystitis is going through a very bad body condition or in high risk by other followed surgeries, the patient should priorly receive medical management with IVs, antibiotics, pain killers. When these treatments stated above have failed, ‘Percutaneous gallbladder drainage’ should be considered. 80% of patients who received this procedure shows clinical improvement within 5 days after the procedure.

- Choledocholithiasis

Gallstones can move from the place of formation inside the gallbladder, and travel through the cystic duct and arrive at the common bile duct. About 15% of patients accompany gallstones in the gallbladder with choledocholithiasis. Many of the common bile duct gallstones(73%) are spontaneously discharged to the duodenum with no particular problems. Patients with choledocholithiasis may be accompanied with gall pain, cholecystitis or pancreatitis and experience expansion on the bile ducts and elevation of liver functional test rates at the same time.

The essential factor in the treatment of choledocholithiasis is the removal of gallbladder and the remaining choledocholithiasis. There are two surgical treatments in the treatment of choledocholithiasis. One is to perform cholecystectomy and removal of the choledocholithiasis at the same time using the laparoscopy, and the other is to first remove choledocholithiasis through endoscopic retrograde cholangio pancreatography before the surgery and then perform laparoscopic cholecystectomy. Although both of these methods have shown same effects on the removal of choledocholithiasis, the former that uses the laparoscopy could shorten the hospitalization period in an average of 3 days.

- Gallstone pancreatitis

As the gallstones travels down along the common bile duct, it may temporarily be jammed at the duodenum’s papilla and cause acute pancreatitis. Once a gallstone pancreatitis occurs, the recurrence rates are very common. 61% of the patients discharged without receiving cholecystectomy are re-hospitalized for recurrent pancreatitis. When compared to gallstone pancreatitis patients who received cholecystectomy on their first hospitalization and patients who did not, patients that have received cholecystectomy after the recurrent gallstone pancreatitis occurred has reported a longer hospitalization period and a bit more on the complications occurrence too(pneumonia, wound infection, cardiac infarction). So for now, cholecystectomy is recommended during the hospitalization period for gallstone pancreatitis. But for patients with very severe the gallstone pancreatitis, too early perform of the cholecystectomy may lead to poor prognosis. Because of this, the International Pancreatic Society recommended to wait for clinical recovery and improvement of pancreatitis before considering biliary tract surgery. Recently the studies about the role of endoscopic retrograde cholangiopancreatography (ERCP) are being proceeded. Compared to a conservative treatment in another recent study, patient that have received ERCP within 72 hours has shown statistically significant number, no reduction in overall complications and mortality. Therefore not every gallstone pancreatitis patient should receive ERCP for now, but it is true that it is effective on patients with obstructive jaundice and cholestasis.

  • * 작성 및 감수 : 대한의학회 / 간담췌외과학회
  • * 출처 : 국가건강정보포털
06 FAQ

Q. Is the gallbladder biogenic?

Luckily, the gallbladder is not an essential organ for the human survival. The liver makes plenty amount of bile that is needed to digest a normal meal. But if the gallbladder is removed, instead of the bile being stored in the gallbladder, it is excreted from the liver directly goes to the small intestine through the liver biliary duct and common bile duct. This makes the bile’s movement to the small intestine more frequent. Because of this, 1% of the patients may have symptoms like more frequent and soft bowel movements. Although these changes are usually temporary, if persists, please consult with a doctor.

Q. If there is no gallbladder, wouldn't there be no more GB stones?

Even if you don’t have a gallbladder, a gallstones may develop in the bile ducts which is the passage that makes biles moves downwards. If this occasion occurs, it becomes the 1% cause of the recurrence of bile duct stones in patients who have received cholecystectomy.

Q. Does the risk of GB stones gets high when I eat lots of calcium contained food?

Just because one ate some anchovies, spinach, or calcium supplements, does not leads to ouccrence of gallstones. So please do not avoid intaking calcium supplements for osteoporosis prevention or calcium-rich foods because of this belief.

Q. Are there special diets to prevent and cure GB Stones?

There are no particular food that is known as good for preventing gallstones after cholecystectomy. But avoiding greasy food and eating evenly foods with no overeating, may help preventing gallstone occurrence. It is also a big help at preventing gallstones if you are not obese and keep the appropriate exercise going on.

Q. Does GB stone comes out when I drink lots of water?

Unlike urinary stones, gallstones don’t tend to come out(or disappear) because the patient drank a lot of water. Cholelithiasis is different from urolithiasis, which creates stones in the kidney and urethra.

Q. What should I do if I have GS stones in my gallbladder, but don’t have any symptoms ?

If you are a patient with gallstones but have a normally functioning gallbladder and experiencing no symptoms, no surgical treatment is necessary. Just visit the hospital for observation using regular abdominal ultrasound at once a year.

Q. Is cholelithiasis related to cancer?

For the case of gallstones in the gallbladder, when the gallbladder wall becomes calcified, this increases the risk of gallbladder cancer. Or if you leave a giant gallstone larger than 2.5-3cm untreated for a long time, it may also increase the risk of gallbladder cancer. However, this does not means that all gallbladder stones eventually leads to cancer, it only happens in some cases. Therefore, please do not remove the gallbladder unconditionally just because you are afraid of getting cancer. If you’re a patient with asymptomatic cholecystolithiasis, it is smart to determine the treatment based on the pros and cons. But on the other hand, among cholecystolithiasis, patients with intrahepatic gallstones have a 4 times higher risk of the possible occurrence of cholangiocarcinoma than the non-patients. And unlike the gallstones in the gallbladder, gallstones in the biliary tract has short bearing period being an asymptomatic gallstone. Once the symptoms occur, in most cases, patients suffer from severe symptoms. So even if the patient doesn’t have any symptoms occurred, it is a principle to remove it as soon as it is discovered. In summary, yes there are cases of cholelithiasis progressing into cancer, but this is only in some special occasions. So it is important to consult with a specialist about which case of gallstones you have. Consequently, if you are not applied in one of the cases described above, receiving abdominal ultrasonography once or twice a year is good enough.

  • * 작성 및 감수 : 보건복지부 / 대한의학회 / 대한외과학회
  • * 출처 : 국가건강정보포털
07 Prevention


The purpose of diet therapy in cholelithiasis is to prevent these 3 things: production of gallstones, pain attacks that may occur in cholelithiasis, and recurrence of cholelithiasis after receiving related treatments.

Dietary therapy for cholelithiasis prevention

Instead of westernized dietary, a Korean styled dietary that evenly eats rice and 3-4 types of side dishes at every meal, is helpful to your health. Well even if the content of the meal is good, overeating is also the cause of cholelithiasis. So it is best if you eat the right amount of food adequate for your body type or eating regularly without skipping meals. Since the standard of living arose, people tend to eat outdoors a lot. This naturally leads to frequent intake of greasy and low-fiber foods, which can also be the cause of cholelithiasis. Therefore it is necessary to choose a menu that provides a balanced diet even when you eat outside. Reducing intake in foods with high cholesterol content is also helpful, these are some foods that has high cholesterol content: egg yolks, squid, shrimp, intestines, eel, etc.

The diet therapy stated above is only applied with cholesterol gallstones patients, when the case of pigment gallstones patients, do not avoid food in particular and moderate intake of meat is also recommended. But why? The reason is that, some of the research results says not enough protein intake may show high occurrence intrahepatic gallstones too.

Dietary therapy if you already have cholelithiasis

If you’re already going through cholelithiasis treatments, a dietary therapy that limits the fat intake and eating appropriate amount of protein, vitamins, minerals is needed. So it is important to follow these following principles. Regardless of the gallstone component(or type) the following dietary therapy is to prevent possible stomach pain from every gallstone patients.

When the symptoms of cholelithiasis are acute and has severe pain or jaundice after the surgery, a strict limitation of fat intake should be proceeded. Avoid using fat(oil, butter, margarine, mayonnaise, salad dressing, etc.) when cooking. When it comes to fish, pick ones with low-fat(frozen pollack, croaker, cod, pomfret, lean meat, etc) and limit daily intake amount less than 150g. If you excessively reduce the amount of fat intake for a long time, this could rather make harmful effects on health. So when symptoms improve, it is recommended to intake a moderate amount of oil(15g per day) when cooking and increase fish and meat intake to 200-250g per day. Vegetables and fruits does not affect on the aggravation of symptoms. Eat regularly and avoid heavy drinking, overeating, pungent food(alcohol, caffeinated drinks, soft drink, etc).

  • * 작성 및 감수 : 대한의학회 / 간담췌외과학회
  • * 출처 : 국가건강정보포털
08 Custom informations for individual cases

Pregnant patient’s cholelithiasis

If you’re a pregnant women with symptomatic cholelithiasis, medical management with jugular vein IVs and pain killers may reduce biliary tract related symptoms. Although there is a research about a pregnant patient who received cholecystectomyduring pregnancy by other methods that has a positive result about both mother and fetus, still there are no studies comparing the performance of early cholecystectomy and medical management to a pregnant patient. So in general, for surgical treatment in pregnant patients, are proceed when the patient is experiencing recurrent cholelithiasis, shows no response after medical management but has constant pain on the biliary tract, complications related to cholelithiasis. The surgery is mostly proceeded at periods that avoids early and late stages of pregnancy.

Liver cirrhosis patients with cholelithiasis

A liver cirrhosis patient with asymptomatic cholelithiasis should be monitored with care. When compensatory liver cirrhosis patients show symptoms caused by cholelithiasis, they should consider receiving a cholecystectomy. Even at studies that have compared results of cholecystectomy that were performed in both patients with or without liver cirrhosis, liver cirrhosis patients did not show difference in mortality. But yes, liver cirrhosis patients has a higher occurrence of overall complications such as hepatorrhagia, and ascites. There is a study about cholecystectomy performed on patients with decompensated cirrhosis, although the results are significant, it has reported high mortality rates. So it is general to provide decompensated cirrhosis patients with symptomatic cholelithiasis more conservative treatment, and these treatments should be done in the purpose of improvement in the liver function before the cholecystectomy.

  • * 작성 및 감수 : 대한의학회 / 간담췌외과학회
  • * 출처 : 국가건강정보포털


01 개요


충수염은 임상에서 수술을 요하는 복통의 가장 흔한 원인이며 매년 우리나라에서 10만명 이상이 급성 충수염으로 수술을 받습니다. 흔히 맹장염으로 부르기도 하나 엄밀하게 말해 맹장염은 정확한 질환 명칭이 아닙니다.

우리 몸의 소화기관은 음식을 씹고 삼키는 입(구강)으로부터 식도, 위, 소장 ,대장을 거쳐 항문을 통해 이루어져 있습니다. 그 중에서 소장에서 대장으로 이어지는 부위에 맹장이라고 불리는 소화기관이 있고 맹장 에 붙어 있는 작은 주머니가 바로 충수입니다.

충수염은 맹장에 붙어있는 이 충수라는 작은 기관에 염증이 생기는 질환이므로 맹장염이라고 하기보다는 급성충수염으로 부르는 것이 의학적으로 맞는 용어입니다.

급성충수염의 임상 양상은 비천공성, 천공성, 천공과 더불어 주위조직의 염증을 동반한 경우, 천공으로 인한 종괴 형성, 범발성 복막염 등으로 나타나게 됩니다. 대개의 경우 치료하지 않으면 충수의 염증은 천공으로 진행됩니다. 따라서 현재까지는 급성충수염이 진단되면 신속하게 수술적 치료를 하는 것이 최선의 방법입니다.

  • * 작성 및 감수 : 대한의학회_대한외과학회
  • * 출처 : 국가건강정보포털
02 원인 및 증상


기본적으로 급성충수염은 어떤 원인에서든지 충수 내부가 막히면서 시작됩니다. 충수가 막히게 되면 충수로부터 대장으로 향하는 정상적인 장의 연동운동이 제한됩니다. 고인 물이 썩듯이 저류가 일어난 상태에서 장내 세균이 증식하고 독성 물질을 분비하게 됩니다. 그러면 이 물질들에 의해서 충수 내부 점막이 손상 받고 궤양을 형성하게 됩니다.

이후 충수 내부의 압력이 증가되면 충수로 가는 동맥혈의 흐름이 저하되고 충수 벽의 전층이 괴사되어 천공으로 진행됩니다.

폐쇄를 일으키는 원인으로는 충수 주위의 임파 조직이 과다 증식 되는 경우가 제일 흔합니다(60%). 다음으로 딱딱한 변이 충수로 흘러들어가서 입구를 막는 경우(35%), 그 외에 이물질, 염증성 협착 등이 원인이 됩니다.

성인에서는 작은 대변 덩어리가 입구를 막아 염증이 생기기도 하며 드물게 이물질, 기생충, 종양으로 인해 충수가 막혀 급성충수염이 되는 경우도 있습니다.

  • 급성 충수염의 발생기전 : 어떤 원인에 의해 충수가 막힘 세균증식/독성 물질 분비 점막 손상/궤양 형성 괴사/천공


급성충수염은 10~20대의 젊은 연령층에서 자주 발생하며, 20대 초반에 가장 흔합니다. 10세 이전이나 50세 이후의 충수염 환자는 전체 충수염 환자의 약 10% 정도를 차지합니다. 대부분의 환자는 증상 발현 후에 12~18시간 안에 의료 기관을 찾게 됩니다. 전체적인 천공률은 약 25%정도이지만 10세 이전(35~60%)과 50세 이후(60~75%)에서는 높은 천공률을 보이기도 합니다.


전체 환자의 절반 정도에서는 전형적인 임상 양상으로 병이 진행하기 때문에 의사라면 간단한 진찰만으로도 쉽게 진단할 수 있습니다. 그러나 비 특이적 양상을 보이는 경우에는 쉽게 진단이 되지 못하여 복막염이나 충수주위농양으로 진행한 후에 수술을 받게 되는 경우도 흔하게 있습니다.

주로 젊은 연령층에서는 비교적 전형적인 양상을 보입니다. 또한, 병의 초기에 항생제나 진통제 같은 약을 복용하게 되는 경우에 통증이 가려지면서 충수주위농양으로 진행하는 경우가 흔히 있습니다. 이런 경우에는 진단이 더욱 어려워집니다.

병이 시작될 때는 식욕이 떨어지고 오심(울렁거림)이 먼저 시작된 후에 상복부 통증이 나타납니다. 이때 1~2회 정도 구토를 하기도 하며, 충수가 위치한 우하복부에는 아무런 이상이 없거나 단지 진찰 시에 미세한 압통만이 나타납니다. 그러므로 이 시기에는 의원에서도 단지 체했다고 생각하기 쉽습니다.

상복부 통증은 시간이 지나면서 배꼽 주위를 거쳐서 우하복부 통증으로 바뀌게 됩니다. 이때에 진찰을 하면 우하복부에 압통이 뚜렷해지고 반발통이 나타납니다. 서서히 미열이 나타나기 시작하고 한기를 느끼기도 합니다.

충수염이 천공되면 통증은 더욱 심해지고 아픈 부위가 우하복부에 국한되지 않고 하복부 전체 또는 복부 전체로 확산됩니다. 40도까지 열이 오르기도 하고 심박동이 빨라집니다.

앞서 얘기한 증상은 전형적인 경우이나 실제 그렇지 않고 전혀 충수염과 거리가 먼 증상으로 시작되는 경우도 있습니다. 따라서 급성충수염의 증상은 매우 다양합니다. 이 때문에 특별히 증상이 드러나지 않아 단순히 체한 줄 알고 아픈 걸 참다가 결국 충수가 터져 천공성 복막염이 된 후 응급실에 실려 가기도 합니다. 이처럼 증상이 애매한 환자가 전체의 3분의 1에 이르며 미국 외과학회지에 따르면 이런 애매한 증상 때문에 수술을 하는 환자가 최대 16%에 이른다고 합니다.

  • * 작성 및 감수 : 대한의학회_대한외과학회
  • * 출처 : 국가건강정보포털
03 진단 및 치료


증상에서 얘기했듯이 많은 사람들이 충수염의 진단을 매우 쉽게 알고 있으나 실제는 그렇지 않은 경우가 많습니다. 전형적인 증상으로 병원을 방문하는 경우에는 대부분의 의료진들이 충수염을 쉽게 의심합니다. 그러나 그렇지 않고 비특이적인 증상을 호소하는 경우에는 충수염을 의심하기가 쉽지 않습니다. 따라서 의료진의 세심한 진찰이 필요한 부분입니다.

급성충수염을 진단할 때 가장 중요한 것은 충수가 위치한 부분을 눌렀을 때 통증(압통)이 있는지 유무입니다. 이 부위를 ‘맥버니 포인트’라고 하는데 정확한 위치는 배꼽과 골반 앞부분이 튀어나온 뼈를 연결한 가상의 선에서 바깥쪽 3분의 1 지점입니다. 앞에서 말한 체한 듯한 증상과 함께 복통, 우하복부, 특히 맥버니 포인트의 압통 유무, 미열, 백혈구 증가 등으로 진단할 수 있습니다. 하지만 증상이 애매하거나 진단이 모호한 경우는 단순한 진찰과 혈액검사 소견만으로 단정하기 어려워 컴퓨터단층촬영이나 초음파 검사를 통해 진단율을 높이기도 합니다. 그러나 수술 전에 이러한 영상학적 진단을 통해 100% 진단을 하는 것이 어려운 경우도 있습니다. 따라서 수술 전 검사에서 충수염에 대한 충분한 근거가 부족할 경우에는 입원해서 경과를 관찰하기도 합니다.


급성 충수염의 치료는 수술이 원칙입니다. 보통 일반인들에게 급성 충수염 수술은 별 것 아닌 수술로 인식되어 있으나 급성충수염 증상이 심한 경우 수술 부위가 커지고 수술도 복잡해질 수 있습니다. 보통 증상이 시작된 시점부터 3일 이내에 수술을 받지 않으면 충수가 터지게 됩니다. 그러면 터진 충수 주위로 고름이 고이는 농양 으로 발전해 복강 내 전체로 고름이 퍼지는 복막염이 생기게 됩니다. 복막염이 생겨 수술을 하게 되면 수술이 커질 뿐 아니라 회복기간이 길어지고 수술 후 패혈증, 장유착 등의 합병증이 생길 수도 있습니다. 최근 수술 흉터를 작게 남기고 빠른 회복을 위해 복강 경을 이용한 수술을 하는 경우도 있습니다. 그러나 충수 주위 조직 손상이 많이 진행된 경우나 복막염을 동반한 천공성 충수염의 경우 복강 경을 이용한 수술이 어려울 수도 있습니다.


충수절제술 후의 합병증은 대부분 감염입니다. 비천공성 충수염의 5%만이 합병증이 생기나, 조직괴사 나 천공이 있는 경우에는 합병증 발생률이 30%에 이르기도 합니다. 천공이 없는 단순 충수염의 수술부위 피부 감염률은 4~8%이고 수술 후 복강 내에 다시 농양 이 생기는 경우는 1% 미만으로 합병증 발생이 많지 않습니다. 그러나 천공이나 조직괴사 가 있을 때는 10~20%에서 수술 부위 피부 감염이 생기며 수술 후 복강 내에 다시 농양 이 생기는 경우가 종종 발생합니다. 드물지만 가장 치명적인 합병증은 범발성 복막염이 있는 경우에 흔히 발생하는 다발성 간농양 을 초래하는 문맥염입니다.


위장염, 장간막림프절염, 대장염 등과 같은 수술이 필요하지 않는 소화기 염증질환과 감별이 필요합니다. 여성의 경우 골반염이나 자궁외임신 등을 감별할 필요도 있으며 그 외에도 요로결석이나 우측 게실염과 같은 질환과 감별도 필요합니다.

  • * 작성 및 감수 : 대한의학회_대한외과학회
  • * 출처 : 국가건강정보포털
04 대상에 따른 충수염

임신 중 충수염

임신 중 충수염은 비임신 여성과 같은 빈도로 발생합니다. 임산부의 경우 태아가 자라면서 점차 커지는 자궁에 의해 충수가 우하복부에서 점차 밀려 올라가 임신말기가 되면 우상복부에 위치하게 됩니다. 그러므로 진단 당시의 임신 개월 수에 따라 압통의 부위가 달라집니다. 충수염이 의심되면 임신 개월 수에 관계없이 조기에 수술하여야만 산모와 태아의 건강에 이롭습니다.

영유아 및 소아의 충수염

어린이는 초기에 자꾸 졸려하고, 자극과민성 및 식욕부진등을 보이며 빨리 진행하여 초기에 구토, 발열 및 동통이 나타나게 됩니다. 흔히 비슷한 증상을 나타내는 질환으로 급성위장관염, 장간막림프절염, 장중첩증, 메켈게실염 등이 있으며 이들 질환과 감별이 요구됩니다.

노인의 충수염

노인의 충수염은 전형적인 증상이 나타나지 않는 경우가 많고, 경과가 빠르며 합병증이 잘 생깁니다. 급성충수염의 증상과 검사소견이 염증을 잘 반영하지 않고, 압통 및 복통의 정도가 젊은이와 같지 않아 진단이 늦어져, 천공성 복막염이나 충수 주위농양으로 진행된 후에야 수술하는 경우가 흔합니다. 흔히 나이 드신 분들의 경우 여러 가지 요인에 의해 표현이 수월하지 않아 늦게 진단되는 경우가 많으므로 갑작스런 소화불량이나 복통을 너무 간과해서는 안 됩니다.

  • * 작성 및 감수 : 대한의학회_대한외과학회
  • * 출처 : 국가건강정보포털

Medical Team

  • 이성하

    Head of Department of Surgery

    Lee Seongha


    Breast, thyroid, varicose vein, gallbladder, appendicitis, burn, dermatopathy(abscess), external wound

  • 홍윤화

    Cheif of Department of Surgery

    Hong Yunhwa


    Colon, anus, hernia, gallbladder, appendicitis, burn, dermatopathy(abscess), external wound