Gallstones (GS) are little, pebble-like crystalline substances that develop in the gallbladder which is a small, pear-shaped sac situated below your liver in the right upper abdomen. Gallbladder helps digestion and accumulates bile produced by the liver. Gallstones develop when liquid stored in the gallbladder hardens into pieces of stone-like substances. The liquid called aids in digesting fats. Bile produced by the liver is stored in the gallbladder as long as the body requires it. The gallbladder contracts and pushes the bile into the common bile duct which transports it to the small intestine, where it takes part in digestion.
Water, cholesterol, fats, bile salts, proteins, and bilirubin (a waste product) are present in the bile. Bile salts break up fat, and bilirubin gives bile and stool a yellowish-brown color. If the liquid bile contains too much cholesterol, bile salts, or bilirubin, it can solidify into gallstones.
There are 2 types of gallstones: cholesterol stones and pigment stones. Cholesterol stones look yellow-green in color and are made mainly of hardened cholesterol. They are responsible for about 80% of gallstones. Pigment stones are little, dark stones in nature and are made of bilirubin. Gallstones can either be as small as a grain of sand or as large as a golf ball in size. There can be just one large stone, hundreds of tiny stones, or a combination of the two in the gallbladder.
What causes gallstones?
Gallstones develop when bile generates solid substances (stones) in the gallbladder.
The stones develop due to high amount of cholesterol or bilirubin in the bile.
Other substances in the bile also may encourage the development of stones.
Pigment stones develop commonly in people having liver disease or blood disease or people having high levels of bilirubin.
Poor muscle tone may resist the gallbladder from emptying totally. The existence of remaining bile may encourage the formation of gallstones.
Risk factors
Gender: Women are doubly susceptible to develop gallstones. Surplus estrogen from pregnancy, hormone replacement therapy, and birth control pills seem to increase amount of cholesterol in bile and slow down gallbladder movement, which can cause gallstones.
Family history: Gallstones often involve family history, indicating a possible genetic connection.
Pregnancy: Pregnant women are more vulnerable to develop gallstones than women who have not been expecting. Pregnancy heightens the risk for cholesterol gallstones because during pregnancy, bile possesses more cholesterol, and the gallbladder stops contracting normally.
Weight: A thorough clinical research showed that being even reasonably overweight raises the possibility of developing gallstones. The most probable reason is that the quantity of bile salts in bile is reduced, causing more cholesterol. Augmented cholesterol decreases gallbladder emptying. Obesity is a key risk factor for gallstones, especially in women.
Diet: High fat diet and cholesterol and low in fiber heighten the risk of gallstones due to the presence of high cholesterol in the bile and reduced gallbladder emptying. Losing a considerable amount of weight promptly on a \”crash\” or starvation diet can also cause risk of having stones in the gallbladder.
Rapid weight loss: As the body metabolizes fat at the time of fasting for a long time and rapid weight loss such as “crash diets”— the liver secretes excess cholesterol into bile, which can develop gallstones. Additionally, the gallbladder does not become empty properly.
Age: People older than age 60 are more at the danger of developing gallstones than younger people. As people age, the body tends to secrete more cholesterol into bile.
Ethnicity: Gallstones are quite common; they occur in about 20% of women in the US, Canada and Europe, but there is a wide variation in predominance among ethnic groups. For instance, gallstones are 1½ to 2 times more common among Scandinavians and Mexican-Americans. Among American Indians, prevalence of gallstones reaches more than 80%.
Cholesterol-lowering drugs: Drugs that help reduce cholesterol levels in the blood actually raise the amount of cholesterol secreted into bile and consequently the risk of having gallstones increases
Diabetes: People suffering from diabetes generally experience elevated levels of fatty acids called triglycerides which may contribute in increasing the risk of gallstones.
Crohn\’s disease: Individuals with Crohn\’s disease of the terminal ileum are more at the risk of developing gallstones. These gallstones develop as patients with Crohn\’s disease lack sufficient bile acids to make the cholesterol soluble in bile. Normally, bile acids entering the small intestine from the liver and gallbladder are absorbed back into the body in the terminal ileum and are secreted once more by the liver into bile. There is lack of enough bile acids which will keep cholesterol dissolved in bile, and thus the gallstones occur.
Gallstones are the most common cause of gallbladder disease:
As the stones get mixed with liquid bile, they can obstruct the outflow of bile from the gallbladder as well as the outflow of digestive enzymes from the pancreas.
If the blockage remains, these organs can be inflamed. Inflammation of the gallbladder is termed as cholecystitis and the inflammation of the pancreas is known as pancreatitis.
Contraction of the blocked gallbladder can increase pressure, bring about swelling, and, sometimes, infection of the gallbladder.
Symptoms
Gallstones usually remain asymptomatic at first. Symptoms generally come in view as complications arise. The most common symptom includes pain in the right upper portion of the abdomen. Because the pain is episodic, it is often called an \”attack.\”
Attacks may take place every few days, weeks, or months; they may even recur after years.
The pain typically begins within 30 minutes following a fatty or greasy meal.
The pain is generally severe, dull, and steady, and can remain from one to five hours.
It may spread to the right shoulder or back.
It occurs commonly at night and may disrupt sleep.
The pain may compel the person to move around to find relief, but many patients desire to lay still and wait for the attack to settle down.
Other common symptoms of gallstones include the following:
Nausea and vomiting
Fever
Indigestion, belching, bloating
Intolerance for fatty or greasy foods
Jaundice (yellowing of the skin or the whites of the eyes)
Diagnosis
Ultrasonography: A high frequency sound waves are allowed to pass through in order to identify abnormalities inside the body.
Cholecystography: It is a use of X-ray after the patient swallowed a dye to sketch out the ducts and gall bladder.
Urine may be tested to exclude kidney infection that can result in abdominal pain similar to that caused by gallstones.
Computerized tomography (CT) scan: The CT scan is a noninvasive x ray that shows cross-section images of the body. The test may show the presence of the gallstones or complications including infection and rupture of the gallbladder or bile ducts.
Cholescintigraphy (HIDA scan): The patient is injected with a slight amount of nonharmful radioactive substance absorbed by the gallbladder, which is then encouraged to contract. The test is performed in order to detect abnormal contraction of the gallbladder or obstacle of the bile ducts.
Endoscopic retrograde cholangiopancreatography (ERCP): ERCP is used to locate and remove stones from the bile ducts. After lightly numbing you, the doctor inserts an endoscope (a long, flexible, lighted tube with a camera) down the throat and through the stomach and into the small intestine. The endoscope is linked with a computer and video monitor. The doctor regulates the endoscope and injects a special dye so that the bile ducts appear clear on the monitor. The endoscope helps the doctor trace the affected bile duct and the gallstone. The stone is gathered in a tiny basket and removed with the help of endoscope.
Blood tests: Blood tests may be done in order to detect signs of infection, obstruction, pancreatitis, or jaundice.
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 immediately. The patient can take some measures to reduce the symptoms:
Drink only clear liquids to give the gallbladder a rest
Avoid fatty or greasy meals
Take acetaminophen (Tylenol, etc.) for pain
Medical Treatment
If you are experiencing recurrent gallbladder attacks, your doctor will possibly recommend you have your gallbladder removed an operation called a cholecystectomy.
Most of the cholecystectomies are performed with laparoscopy. After giving you medication to anesthetize you, the surgeon does several tiny incisions in the abdomen in order to insert a laparoscope and a minuscule video camera. The camera sends an enlarged image from inside the body to a video monitor, enabling the surgeon to see the close-up of the organs and tissues. While viewing the monitor, the surgeon uses the instruments to cautiously detach the gallbladder from the liver, bile ducts, and other internal body structures. Then the surgeon makes an incision on the cystic duct and eliminates the gallbladder through one of the small incisions.
Recovery after laparoscopic surgery usually needs only one night stay in the hospital, and normal activity can be started after a few days at home. Because the abdominal muscles are not separated during laparoscopic surgery, patients experience less pain and fewer complications than after going through “open” surgery that requires a 5- to 8-inch incision across the abdomen.
If tests reveal that the gallbladder is severely inflamed, infection, or scarring from other operations, the surgeon may execute open surgery in order to eliminate the gallbladder. In some cases, open surgery is planned previously; however, sometimes these problems occur at the time of the laparoscopy and the surgeon has to make a larger incision.
If gallstones remain in the bile ducts, the physician usually a gastroenterologist may follow ERCP to identify and eliminate them prior to or during gallbladder surgery. Seldom, a person who has had a cholecystectomy is identified with a gallstone in the bile ducts weeks, months, or even years subsequent to the surgery. The ERCP procedure is usually effective in eliminating the stone in these situations.
Extracorporeal shockwave lithotripsy (ESWL): A mechanism generating shock waves is used to help break gallstones up into small pieces.
These little pieces can traverse the biliary system causing no blockages
This is usually done in combination with ERCP to eliminate some stones
Many people undergoing this treatment suffer attacks of intense pain in the right
upper part of the abdomen following treatment
The usefulness of ESWL in treating
Gallstones have not been completely established
Dissolving stones:
Drugs produced from bile acids are prescribed to dissolve the gallstones
It may take months or even years to dissolve all the gallstones
The stones often develop after this treatment
These drugs are quite effective to treat cholesterol stones
Do people live without Gallbladder
Luckily, people can live without the gallbladder. Your liver produces sufficient amount of bile so that you can digest a normal diet. Once the gallbladder is removed, the bile can no longer be stored in the gallbladder and it flows out of the liver through the hepatic ducts into the common bile duct and directly into the small intestine.
Prevention
There is hardly any method known that can prevent gallstones. If you have gallstone symptoms, having a low-fat diet and losing weight may help you manage symptoms.