Gallstones

Gallstones



Definition of Gallstones

Gallbladder is an organ that is present just below the liver, on right side of the body, in the upper abdominal region. In appearance, it is pear shaped. It stores a fluid called bile (greenish liquid), which is secreted from liver. From liver, it is stored temporarily in gallbladder where it is concentrated. It is secreted from gallbladder into the first part of intestine through bile duct (narrow duct extending from gall bladder to intestine, joining with other ducts in its pathway), where it helps in the absorption of fat.

The hard, stone like mass or masses formed inside the gallbladder or its duct are called gallstones. In medical science, this is called cholelithiasis. Gallstones may be one or more than one in number. There are numerous sizes of gallstones. They may be as small as a grain of sand or may be as large as a golf ball. These are formed mainly in gallbladder but they may migrate as a whole or a part of them migrates to the narrow bile duct or other associated ducts causing further complication of this condition. When the gallstones are present in the common bile duct, clinically, it is called choledocholithiasis. Following are the three main types of gallstones, based on their chemical composition:

  • Cholesterol gallstones

  • Pigment gallstones

  • Mixed gallstones

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Cause of Gallstones

Under certain circumstances, when there is some imbalance of substances in body, the substances that are present inside gallbladder as a part of bile (like cholesterol, calcium, calcium carbonate and bilirubin etc) are concentrated and start forming small masses in the bile. With the passage of time, these masses grow in size and are hardened into stone like structures called gallstones. These stones, with the passage of time, increase in size and start filling the lumen of gallbladder. Gallstones are mostly made of different proportions of the substances present inside gallbladder (like mixed gallstones). Rarely, these are made of one pure substance (like cholesterol or pigment gallstones). The composition of gallstones is affected by:

  • Age

  • Diet

  • Ethnicity

  • Health status of body

Following are the major causes of gallstones formation:

  • Increased cholesterol level in the body(thus increased cholesterol in bile)

  • Increased bilirubin level (which is a waste product of red blood cells break down)

  • Improper emptying of gall bladder (leading to concentration of bile and gallstones formation)

  • Complication due to some disease (like diabetes, crohn’s disease and inflammatory bowel disorder etc)

  • Side effect of some medicines (like octreotide)

  • Blood disorder

  • Genetic risk factors

Signs and Symptoms of Gallstones

Most of the time, these stones are asymptomatic, meaning no signs and symptoms are present. The reason is that the gallstones generally stay in the gallbladder and do not cause any problem inside it (that is why they are also called silent stones). However, sometimes they show typical signs and symptoms.

  • If these stones irritate or damage the gallbladder, it lead to the inflammation of gall bladder (called cholecystitis).

  • If they are passed through narrow ducts associated with gallbladder, they lead to the damage or obstruction of these ducts.

Typical signs and symptoms associated with gallstones are:

  • Sudden and intensifying pain that is felt just below the ribs, on right side of the body and in the center of the abdomen (it may last for minutes or few hours)

  • Referred pain in the right shoulder and area between the shoulder blades

  • Mostly the pain is felt after taking a fatty meal, at night or after drink

  • Positive Murphy’s sign on physical examination by Doctor

  • Nausea

  • Vomiting

  • Restlessness

 


When gallstones cause the infection of gallbladder, the signs and symptoms may include fever and shivering, in addition to the typical signs and symptoms.

When gallstones from gallbladder travel down the duct and are large enough to block it, the flow of bile is obstructed. In that case bile goes into the blood and causes additional signs and symptoms of jaundice (yellowing of eyes and skin).

The most common and important sign and symptom of gallstones is biliary colic. It is a very specific, severely painful condition that is associated with sudden obstruction of common bile duct or hepatic duct. It is ar symptom that is present in majority people having gallstones.

It is a constant pain that develops suddenly or rapidly within few minutes. It lasts for 15 minutes or about 5 hours. This is a recurring pain, which means after first episode there are fair chances of other episodes as well.

The pain of gallstones must always be differentiated from heartburn, liver problems, stomach flu and food poisoning because these conditions also have almost similar signs and symptoms as the gallstones.

 

Risk Factors for Gallstones

Following are some of the most common risk factors for gallstones formation:

  • Obesity

  • Rapid weight loss

  • Intense dieting

  • Prolonged intravenous infusion

  • Crohn’s disease (an inflammatory bowel disorder)

  • Cirrhosis of liver (scarring of liver)

  • Blood disorders (like sickle cell anemia causing increased bilirubin level in body)

  • Metabolic syndrome (multiple problems occur in this condition like increased cholesterol level, increased blood pressure, low good cholesterol and increased blood sugar etc)

  • Increased consumption of iron containing food

  • Intake of cholesterol lowering medicines

  • Bone marrow transplantation

  • Genetics (having family history of gallstones)

  • Diabetes

  • Ethnicity ( more common in north and south Americans)

  • Children having abdominal surgery, sickle cell anemia, spinal injury and defective immune system etc

  • Pregnancy

  • Women (specially old age, using contraceptive or undergoing estrogen replacement therapy)

  • Old age

Diagnosis of Gallstones

Gallstones are mostly asymptomatic so they are diagnosed when their complications occur and signs and symptoms start appearing or accidently when a patient is being monitored for another illness etc. Following are the most common procedures that are used for the diagnosis of gallstones:

  • Blood tests (for cholesterol level, jaundice, pancreatitis, obstruction or signs of infection etc)

  • X-rays of right side of abdomen

  • CT scan of right side of abdomen

  • Ultrasound of abdomen

  • Cholangiography

Prevention from Gallstones

  • Among the risk factors mentioned before, some can be managed and controlled (like weight, body health etc) while some cannot be managed and controlled (like age, sex ethnic group etc) for the prevention of gallstones. Some general preventive measures are:

    • Low fat diet

    • Increased proportion of vegetables and fruits in diet

    • Daily use of nuts

    • Weight loss in case of obesity

    • Regular exercise

    • Keeping good health status

    • Increased fibers in diet

Treatment of Gallstone

Following are the treatment options for the gallstones:

  • Medication

Gallstones do not indicate a defect in gallbladder. It simply shows some imbalance of substances in the body and this imbalance must be corrected first by proper medication rather than removing the gallbladder. In addition to that, some medicines are given orally to dissolve or break the gallstones inside the body.

  • Surgery

It is only done in patients showing symptoms or the use of medicines is not giving desired results. The surgical procedure done in that case is the removal of gallbladder, called cholecystectomy. The removal of gallbladder does not cause any serious negative effect on body because the liver can produce enough bile for normal body function.

However, in some people, after surgery, post-cholecystectomy syndrome develops. In that case there is git distress, continuous pain in upper abdomen, on right side and sometimes chronic diarrhea.

  • Lithotripsy

In that procedure, gallstones are broken by using ultrasound shock waves on body.

  • ERCP (endoscopic retrograde cholangiopancreatography)

It is done in rare cases when the medicines, surgery and other procedures are not an option for the patient.If the signs and symptoms of gallstones continue after treatment, even after the removal of gallbladder, that might means:

  • Gallstones are left somewhere, other than the bladder like any duct associated with the gallbladder.

  • Bile ducts were also having gallstones which are left behind.

  • Gallstones were not the cause of signs and symptoms shown by the patient.