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Gallstones Overview

Gallstones (commonly misspelled gall stones or gall stone) are solid particles that form from bile in the gallbladder.

The gallbladder is a small saclike organ in the upper right part of the abdomen. It is located under the liver, just below the front rib cage on the right side. The gallbladder is part of the biliary system, which includes the liver and the pancreas. The biliary system, among other functions, produces bile and digestive enzymes.

Bile is a fluid made by the liver to help in the digestion of fats.

It contains several different substances, including cholesterol and bilirubin, a waste product of normal breakdown of blood cells in the liver. Bile is stored in the gallbladder until needed. When we eat a high-fat, high-cholesterol meal, the gallbladder contracts and injects bile into the small intestine via a small tube called the common bile duct. The bile then assists in the digestive process.

There are two types of gallstones: 1) cholesterol stones and 2) pigment stones.

1. Patients with cholesterol stones are more common in the United States; cholesterol stones make up approximately 80% of all gallstones. They form when there is too much cholesterol in the bile. 2. Pigment stones form when there is excess bilirubin in the bile. Gallstones can be any size, from tiny as a grain of sand to large as a golf ball.

Although it is common to have many smaller stones, a single larger stone or any combination of sizes is possible. If stones are very small, they may form a sludge or slurry. Whether gallstones cause symptoms depends partly on their size and their number, although no combination of number and size can predict whether symptoms will occur or the severity of the symptoms.

Gallstones within the gallbladder often cause no problems. If there are many or they are large, they may cause pain when the gallbladder responds to a fatty meal. They also may cause problems if they move out of the gallbladder.

If their movement leads to blockage of any of the ducts connecting the gallbladder, liver, or pancreas with the intestine, serious complications may result. Blockage of a duct can cause bile or digestive enzymes to be trapped in the duct. This can cause inflammation and ultimately severe pain, infection, and organ damage. If these conditions go untreated, they can even cause death.

Up to 20% of adults in the United States may have gallstones, yet only 1% to 3% develop symptoms.

Hispanics, Native Americans, and Caucasians of Northern European descent are most likely to be at risk for gallstones. African Americans are at lower risk. Gallstones are most common among overweight, middle-aged women, but the elderly and men are more likely to experience more serious complications from gallstones. Women who have been pregnant are more likely to develop gallstones. The same is true for women taking birth control pills or on hormone/estrogen therapy as this can mimic pregnancy in terms of hormone levels.

Gallstones Causes

Gallstones occur when bile forms solid particles (stones) in the gallbladder.

The stones form when the amount of cholesterol or bilirubin in the bile is high. Other substances in the bile may promote the formation of stones. Pigment stones form most often in people with liver disease or blood disease, who have high levels of bilirubin. Poor muscle tone may keep the gallbladder from emptying completely. The presence of residual bile may promote the formation of gallstones.

Risk factors for the formation of cholesterol gallstones include the following:

female gender, being overweight, losing a lot of weight quickly on a "crash" or starvation diet, or taking certain medications such as birth control pills or cholesterol lowering drugs.

Gallstones are the most common cause of gallbladder disease.

As the stones mix with liquid bile, they can block the outflow of bile from the gallbladder. They can also block the outflow of digestive enzymes from the pancreas. If the blockage persists, these organs can become inflamed. Inflammation of the gallbladder is called cholecystitis. Inflammation of the pancreas is called pancreatitis. Contraction of the blocked gallbladder causes increased pressure, swelling, and, at times, infection of the gallbladder.

When the gallbladder or gallbladder ducts become inflamed or infected as the result of stones, the pancreas frequently becomes inflamed too.

This inflammation can cause destruction of the pancreas, resulting in severe abdominal pain. Untreated gallstone disease can become life-threatening, particularly if the gallbladder becomes infecte

Gallstone Symptoms
What Are the Symptoms of Gallstones?
As gallstones move into the bile ducts and create blockage, pressure increases in the gallbladder and one or more symptoms may occur. Symptoms of blocked bile ducts are often called a gallbladder "attack" because they occur suddenly. Gallbladder attacks often follow fatty meals, and they may occur during the night. A typical attack can cause

steady pain in the right upper abdomen that increases rapidly and lasts from 30 minutes to several hours pain in the back between the shoulder blades pain under the right shoulder

Notify your doctor if you think you have experienced a gallbladder attack. Although these attacks often pass as gallstones move, your gallbladder can become infected and rupture if a blockage remains. People with any of the following symptoms should see a doctor immediately:

prolonged pain - more than 5 hours nausea and vomiting fever - even low-grade - or chills yellowish color of the skin or whites of the eyes clay-colored stools

Many people with gallstones have no symptoms; these gallstones are called "silent stones." They do not interfere with gallbladder, liver, or pancreas function and do not need treatment.

Gallstones and Diet

The role of diet in the formation of gallstones is not clear.

We do know that anything that increases the level of cholesterol in the blood increases the risk of gallstones. It is reasonable to assume that a diet with large amounts of cholesterol and other fats increases the risk of gallstones, but it is also important to remember that the amount of cholesterol in your bile has no relationship to your blood cholesterol. Loosing weight rapidly seems to increase the risk of gallstones and so does skipping meals. Obesity is a risk factor for gallstones.

Eating a fatty or greasy meal can precipitate the symptoms of gallstones.

Gallstones Symptoms
Most people with gallstones (60% to 80%) have no symptoms. In fact, they are usually unaware that they have gallstones unless symptoms occur. These "silent gallstones" usually require no treatment. Symptoms usually occur as complications develop. The most common symptom is pain in the right upper part of the abdomen. Because the pain comes in episodes, it is often referred to as an "attack."

Attacks may occur every few days, weeks, or months; they may even be separated by years. The pain usually starts within 30 minutes after a fatty or greasy meal. The pain is usually severe, dull, and constant, and can last from one to five hours. It may radiate to the right shoulder or back. It occurs frequently at night and may awaken the person from sleep. The pain may make the person want to move around to seek relief, but many patients prefer to lay still and wait for the attack to subside.

Other common symptoms of gallstones include the following:

nausea and vomiting, fever, indigestion, belching, bloating, intolerance for fatty or greasy foods, and jaundice (yellowing of the skin or the whites of the eyes).

Gallstones Diagnosis
Upon hearing the patient's symptoms, the health care practitioner will probably suspect gallstones. Because the symptoms of gallbladder disease can resemble those of other serious conditions, he or she will ask the patient questions and examine them to try to confirm this diagnosis and rule out other conditions. There is no blood test that can identify gallstones.

Blood will be taken for tests that can help to determine if the gallbladder is obstructed, if the liver or pancreas is inflamed or not functioning properly, or if the patient has an infection. If you are a woman, the blood may also be tested to check for a possible pregnancy, Urine may be tested to rule out kidney infection. Kidney infections can cause abdominal pain similar to that caused by gallstones.

Ultrasound is the best test to examine the gallbladder for stones.

Ultrasound uses painless sound waves to create images of organs. Ultrasound examinations are very good at seeing abnormalities in the biliary system, including stones or signs of inflammation or infection. This is the same technique used to look at a fetus in a pregnant woman. Finding gallstones by ultrasound does not diagnose gallbladder disease. The doctor has to correlate the ultrasound findings with the patient's symptoms.

An alternative to ultrasound is an oral cholecystogram (OCG).

An X-ray is taken of the gallbladder after the patient swallow pills containing a safe, temporary dye. The dye helps the gallbladder and gallstones show up better on the X-ray.

Both ultrasound and OCG can detect gallstones in the gallbladder about 95% of the time.

Ultrasound is usually the first choice because it is completely noninvasive and involves no exposure to radiation. If either test gives an uncertain result, another test usually is necessary.

These tests are the alternatives to ultrasound and OCG. They are better choices if gallstones have left the gallbladder and moved into the ducts.

Cholescintigraphy (HIDA scan): This is a test in which a solution is injected into an IV line in the patient's arm. The liquid is absorbed by the liver, then passed on to be stored in the gallbladder (much like bile). The solution contains a harmless radioactive marker, which is seen by a special camera. If the gallbladder is inflamed or blocked by gallstones, none of the marker is seen in the gallbladder.

CT scan: This test is similar to an X-ray, however more detailed. It shows the gallbladder and the biliary ducts and can detect gallstones, blockages, and other complications. Endoscopic retrograde cholangiopancreatography (ERCP): A thin, flexible endoscope is used to view parts of the patient's biliary system. The patient is sedated, and the tube is passed through the mouth and stomach and into the small intestine. The device then injects a temporary dye into the biliary ducts. The dye makes it easy to see any stones in the ducts when X-rays are taken. Sometimes a stone can be removed during this procedure.

A chest X-ray may be performed to make sure there are no other reasons for the abdominal pain.

Sometimes problems in the chest (such as pneumonia ) can cause pain in the upper abdomen. Occasionally the chest X-ray can also show stones in the gallbladder.

As most gallstones are asymptomatic, many times gallstones are diagnosed when the patient undergoes a test for another reason.

Gallstones Treatment Self-Care at Home

After a diagnosis of gallstones, the patient may choose not to have surgery or may not be able to have surgery right away. There are measures the patient can take to relieve the symptoms to include:

intake of only clear liquids to give the gallbladder a rest, avoid fatty or greasy meals, and take acetaminophen (Tylenol, etc.) for pain.

Call a health care practitioner if symptoms worsen or if new symptoms appear. Abdominal pain with vomiting, fever, or jaundice warrants an immediate visit to a doctor's office or a hospital emergency department.

Gallstone Medical Treatment

There is no permanent medical cure for gallstones. Although there are medical measures that can be taken to remove stones or relive symptoms, they are only temporary. If a patient has symptoms from gallstones, surgical removal of the gallbladder is the best treatment. Asymptomatic (producing no symptoms) gallstones do not require treatment.

Extracorporeal shockwave lithotripsy (ESWL): A device that generates shock waves is used to break gallstones up into tiny pieces.

These tiny pieces can pass through the biliary system without causing blockages. This is usually done in conjunction with ERCP to remove some stones. Many people who undergo this treatment suffer attacks of intense pain in the right upper part of the abdomen after treatment. The effectiveness of ESWL in treating gallstones has not been fully established.

Dissolving stones: Drugs made from bile acids are used to dissolve the gallstones.

It may take months or even years for the gallstones to all dissolve. The stones often come back after this treatment. These drugs work best for cholesterol stones. They cause mild diarrhea in many people. This treatment is usually offered only to people who are not able to have surgery.

If an individual goes to an emergency department, an IV line may be started, and pain medication and antibiotics may be given through the IV. If the patient's health permits it, the health care practitioner will probably recommend surgery to remove the gallbladder and the stones. Surgical removal helps prevent future episodes of abdominal pain and more dangerous complications such as inflammation of the pancreas and infection of the gallbladder and liver.

If there is no infection or inflammation of the pancreas, the operation to remove the gallbladder can be performed immediately or within the next several days. If there is inflammation of the pancreas or infection of the gallbladder, the patient will most likely be admitted to the hospital to receive IV fluid and possibly IV antibiotics for several days prior to the operation.

Gallstone Surgery (Cholecystectomy)

The usual treatment for symptomatic or complicated gallstones is surgical removal of the gallbladder. This is called cholecystectomy. Many people who have gallbladder disease are understandably concerned about having their gallbladder removed. They wonder how they can function without a gallbladder.

Fortunately, you can live without your gallbladder. Living without a gallbladder does not require a change in diet. When the gallbladder is gone, bile flows directly from the liver into the small intestine. Because there is nowhere to store bile, sometimes bile flows into the intestine when it is not needed. This does not cause a problem for most people, but causes mild diarrhea in about 1% of patients.

Laparoscopic removal: Most gallbladders are removed by laparoscopic cholecystectomy. The gallbladder is removed through a small slit in the abdomen using small tube-like instruments.

The tube-like instruments have a camera and surgical instruments attached, which are used to take out the gallbladder with the stones inside it. This procedure causes less pain than open surgery. It is less likely to cause complications, and has a faster recovery time. A laparoscopic procedure is preferred if it is appropriate for the patient. The procedure is performed in an operating room with the patient under general anesthesia. It usually takes 20 minutes to one hour. A general surgeon performs the operation. In some cases a laparoscopic procedure is started and then changed to an open abdominal procedure (see below).

Open removal: The gallbladder is sometimes removed through a 3 to 6 inch incision in the right upper abdomen.

The open procedure usually is used only when laparoscopic surgery is not feasible for a specific person. Common reasons for doing an open procedure are infection in the biliary tract and scars from previous surgeries. About 5% of all gallbladder removals in the United States are done as open procedures. This procedure is performed in the operating room with the patient under general anesthesia.

It usually takes 45 to 90 minutes. A general surgeon performs the operation.

Occasionally, ERCP is done just before or during surgery to locate any gallstones that have left the gallbladder and are located elsewhere in the biliary system. These can be removed at the same time as surgery, eliminating the risk that they might cause a complication in the future. ERCP also may be performed after surgery if a gallstone is later found in the biliary tract. Sometimes ERCP is done without surgery, for example in people who are too frail or ill to undergo surgery.

Gallstone Outlook
If gallstones block one of the biliary ducts, the result is inflammation and swelling of the organs "upstream" of the blocked duct.

This complication alone can cause symptoms and warrants treatment, possibly surgery. If untreated, it can lead to more serious conditions such as infection and damage to the gallbladder, liver, and pancreas. If these organs sustain enough damage, they can no longer carry out their normal functions. This is a life-threatening complication.

If a patient has surgery, you should know the following:

A person who has had laparoscopic surgery to remove the gallbladder may leave the hospital 12-48 hours after surgery and return to full activities within three weeks. If open surgery was required to remove the gallbladder, recovery takes a little longer. The person may leave the hospital within three to seven days and could resume normal activity after a six week recovery period. The most common complication of surgery is damage to the biliary tract. If bile leaks out of the biliary system, it can cause an infection.

If a person chooses not to have their gallbladder removed, it is likely you will have recurring abdominal pain and possibly complications.