Gallstones

Definition

Gallstones are hard, pebble-like deposits that form inside the gallbladder. Gallstones may be as small as a grain of sand or as large as a golf ball, depending on how long they have been forming.

Alternative Names

Cholelithiasis

Causes

The cause of gallstones varies. Some stones form when there is too much cholesterol or bilirubin in the bile. (Bile is a liquid that helps the body digest fats.) Other stones form if there are not enough bile salts or if the gallbladder fails to empty properly.

One type of gallstones, called pigment stones, tend to occur in people who have medical conditions that cause the liver to make too much bilirubin. Pigment stones are also more common in persons with liver cirrhosis and biliary tract infections.

Gallstones are a common health problem worldwide. They are more common in women, Native Americans, and people over the age of 40.

Other risk factors include ethnic and genetic factors, obesity, diabetes, cirrhosis, receiving nutrition through a vein for a long period of time (intravenous feedings), and certain operations for peptic ulcers.

Symptoms

There are usually no symptoms. Gallstones are usually discovered when having a routine x-ray, abdominal surgery, or other medical procedure.

Symptoms usually occur if a large stone blocks the cystic duct or the common bile duct. The cystic duct drains fluid from the the gallbladder into the the common bile duct, which is the main duct draining into the duodenum. Together, these ducts form part of the biliary system.

A stone blocking the opening from the gallbladder or cystic duct usually produces a cramping pain in the middle to right upper abdomen. This is known as biliary colic. The pain goes away if the stone passes into the first part of the small intestine (the duodenum). Acute cholecystitis occurs if the stone does not pass into the duodenum.

If the common bile duct is blocked for a long period of time, pancreatitis or cholangitis may result.

Symptoms that may occur include:

• Abdominal pain in the right upper or middle upper abdomen:
  • May be recurrent
  • May be sharp, cramping, or dull
  • May spread to the back or below the right shoulder blade
  • May be made worse by fatty or greasy foods
  • Occurs within minutes of a meal
• Fever
• Yellowing of skin and whites of the eyes (jaundice)

Additional symptoms that may be associated with this disease include:

• Abdominal fullness
• Clay-colored stools
• Excess gas
• Heartburn
• Indigestion
• Nausea and vomiting

It is important to see a doctor if you have symptoms of gallstones. Gallstones are found in many people with gallbladder cancer.

Exams and Tests

Tests used to detect gallstones or gallbladder inflammation include:

• Abdominal ultrasound
• Abdominal CT scan
• Abdominal x-ray
• Endoscopic retrograde cholangiopancreatography (ERCP)
• Gallbladder radionuclide scan
• Oral cholecystogram

This disease may also alter the results of the following tests:

• Abdominal MRI
• Fecal fat
• Urine bilirubin

Treatment

Modern advances in surgery have revolutionized the treatment of gallstones. In general, surgery is used only if you have symptoms.

In the past, open cholecystectomy (gallbladder removal) was the usual procedure for uncomplicated cases. Today, a minimally-invasive technique called laparoscopic cholecystectomy is most commonly used. This procedure uses smaller surgical cuts, which allow for a faster recovery. A patient may have their gallbladder removed in the morning and be sent home from the hospital on the same day or the next morning.

MEDICATION

If your gallbladder works properly, bile salts taken by mouth may dissolve gallstones. However, the process may take 2 years or longer, and stones may return after treatment ends.

Medicines called chenodeoxycholic acids (CDCA) or ursodeoxycholic acid (UDCA, ursodiol) may be given to dissolve the stones. Both CDCA and UDCA are useful only for gallstones formed from cholesterol.

In some cases, chemicals are passed into the gallbladder through a catheter. The chemical rapidly dissolves cholesterol stones, but potential toxicity, stone recurrence, and other complications limit its usefulness.

LITHOTRIPSY

Electrohydraulic shock wave lithotripsy (ESWL) has also been used to treat gallstones. However, its application is limited if there are a large number of stones present, if the stones are very large, or in the presence of acute cholecystitis or cholangitis. It can also be used in association with UDCA to improve its effect.

Outlook (Prognosis)

Gallstones develop in many people without causing symptoms. The chance of symptoms or complications from gallstones is about 20%. Nearly all patients (99%) who have gallbladder surgery do not have their symptoms return.

Possible Complications

• Acute cholecystitis
• Cholangitis
• Cholecystitis - chronic
• Choledocholithiasis
• Pancreatitis

When to Contact a Medical Professional

Call for an appointment with your health care provider if you have:

• Pain in the right upper part of your abdomen
• Yellowing of the skin or whites of the eyes

Prevention

There is no known way to prevent gallstones. If you have gallstone symptoms, eating a low-fat diet and losing weight may help you control symptoms.

References

Siddiqui T. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a meta-analysis of randomized clinical trials. Am J Surg. Jan 2008; 195(1): 40-7.

Chari RS, Shah SA. Biliary System. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery, 18th ed. St. Louis, M0: WB Saunders; 2008: chap. 54.

Diseases of the Gallbladder and Bile Ducts. In: Goldman L, Ausiello D, eds. Cecil Textbook of Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap. 159.