GALLSTONES

OVERVIEW

Gallstones are solid, pebble-like concretions that form inside the gallbladder. The gallbladder is located in the upper right abdomen, under the liver.

More than one million Americans are diagnosed with gallstones (cholelithiasis) every year, joining about 38 million who already have the disorder. Fortunately, most people with gallstones do not have symptoms and do not require treatment. In some cases, however, gallstones cause pain or other complications and must be treated, usually by removing the entire gallbladder with its stones.

THE GALLBLADDER 

The gallbladder is a pear-shaped sac-like organ with a muscular wall that is about three to six inches (7.5 to 15 cm) long, located in the right upper side of the abdomen, under the liver. It is connected to the liver and intestine through small tubes called bile ducts.

The primary purpose of the gallbladder is to store and concentrate bile, a greenish-brown fluid that is produced by the liver. Bile carries waste products out of the liver but it is also needed to digest and absorb fatty foods, and to absorb important fat-soluble vitamins. Between meals, the gallbladder is relaxed, allowing bile to flow into it, where bile is stored and concentrated. With meals, the fat content of foods in the small intestine cause the gallbladder to contract (squeeze) and partially empty into the intestine. A few hours later, the gallbladder relaxes and begins to store bile again.

WHAT ARE GALLSTONES? 

Gallstones are solid concretions that form inside the gallbladder. Gallstones may be as small as tiny specks or as large as the gallbladder itself. The vast majority, however, are smaller than one inch (2.5 cm) and are one of two major types, cholesterol or pigment.

• Cholesterol gallstones account for approximately 80 percent of gallstones in developed countries, including the United States.
• Pigment stones account for about 20 percent of gallstones.

RISK FACTORS FOR GALLSTONES 

Experts do not know for sure why gallstones develop. However, many people have bile with an abnormally high concentration of cholesterol and/or calcium from which stones may develop. There are a number of factors that increase the risk of developing gallstones

• Sex – Gallstones are more common in women.
• Age – The risk of gallstones increases with age. The condition is extremely rare in children and becomes progressively more frequent over time, especially after the age of 40 years.
• Family history and genetics – Gallstones are more common in certain families, suggesting that genetics has a role in gallstone development.
• Other factors – Other conditions can increase the risk of developing gallstones, including:
  • Pregnancy
  • Use of medicines that contain estrogen (such as birth control pills).
  • Obesity
  • Frequent fasting
  • Rapid weight loss (including patients who have surgical weight loss treatments)
  • Lack of physical activity
  • Diabetes mellitus
  • Sickle cell disease (and other conditions associated with rapid destruction of red blood cells, such as in patients with mechanical heart valves).
  • Cirrhosis or severe scarring of the liver.
  • Certain medicines.

GALLSTONE SYMPTOMS

Silent gallstones — The majority of people who have gallstones do not have symptoms; their stones remain "silent." Silent gallstones are often found on an ultrasound or CT scan done for other reasons. Silent stones do not need to be treated since the first symptoms of gallstones are usually mild and there are risks involved in removing the gallbladder.

If you have silent gallstones, you should be aware of the initial symptoms of gallstone disease because you may need treatment if you develop symptoms.

Biliary colic — Biliary colic, also known as gallstone pain or biliary pain, is the most common initial symptom of gallstones. It manifests as attacks of abdominal pain, often located in the right upper belly just under the lower ribs. Sometimes it is felt in the upper center of the abdomen or even in the lower chest, causing it to be confused with angina or a heart attack. You may also feel nausea, and vomiting, and pain in the right shoulder or back.

Biliary colic usually happens when the gallbladder contracts in response to a fatty meal. This compresses the stones against the gallbladder outlet, blocking its opening. As the gallbladder relaxes several hours after the meal, the pain subsides. In some people, the pain happens without having eaten anything and many times it starts around or after midnight.

Once you have a first attack of biliary colic, there is a good chance you will have more symptoms in the future. Such recurrent symptoms are usually more severe and occasionally associated with complications.

Complications of gallstones

Acute cholecystitis — Acute cholecystitis refers to inflammation of the gallbladder. This happens when there is a complete blockage of the gallbladder, caused by a gallstone. Unlike biliary colic, which resolves within a few hours, pain is constant with acute cholecystitis and fever is common.

Acute cholecystitis is a serious condition that requires immediate medical treatment in the hospital. Treatment includes IV fluids, pain medicine, and usually antibiotics. Surgery to remove the gallbladder along with its contained stones is usually recommended during the hospitalization or shortly thereafter. If not treated, acute cholecystitis can lead to gallbladder rupture, a life-threatening condition.

Choledocholithiasis — This complication can develop if one or more gallstones leave the gallbladder to the main bile ducts and block the area where bile exits into the intestine. It may lead to:

• Jaundice, which is a yellow discoloration of the skin and eyes.
• Acute cholangitis, which is an infection of the bile ducts that causes pain, chills, and fever. This is a life-threatening condition that requires prompt treatment, usually involving removal of the blocking gallstone with a non-surgical procedure known as endoscopic retrograde cholangiopancreatography, or ERCP.
• Acute pancreatitis, which is sudden inflammation of the pancreas, leading to severe abdominal pain.

GALLSTONE DIAGNOSIS  

There are two parts to diagnosing gallstones: determining if gallstones are present, and determining if gallstones are the cause of symptoms.

Gallstones are usually found using ultrasound imaging, a painless test that uses sound waves to create an image of the gallbladder. An ultrasound is the most sensitive test with which to find gallbladder stones, but gallstones can also be seen on other imaging tests

Having gallstones does not mean that the gallstones are the cause of your symptoms. Thus, other tests may be recommended if there is doubt about the relationship of the gallstones to your symptoms.