Gallstones are solid deposits of cholesterol or calcium salts that form in the gallbladder or the bile ducts nearby. These stones often cause no symptoms and do not need treatment. In some individuals, a gallbladder attack occurs with symptoms such as nausea and an intense, constant or intermittent ache in the upper middle or right side of the abdomen. There is an increased risk of developing gallstones in older, overweight females. Rapid weight loss or the consumption of a very low calorie diet may also increase the risk of developing gallstones. If left untreated, complications from gallstones could be very serious and sometimes fatal.
The liver produces bile, a greenish-brown fluid made up of bile salts, cholesterol, fatty compounds and other chemicals. This fluid aids digestion by emulsifying fats in the small intestine. It is concentrated and stored in the gall bladder and released when needed. During meals, the gallbladder contracts releasing bile through the cystic duct to the common bile duct which in turn is released into the duodenum (upper part of the small intestine). If bile becomes chemically unbalanced, it can form hardened particles which eventually grow into stones over a long period of time (several years). Gallstones range in size from as small as a grain of sand to as large as a golf ball and may be smooth and round or have irregular rough edges. There are three categories of gallstones namely: Cholesterol gallstones (which make up 80% of gallstones) which are usually yellow in colour, composed of undissolved cholesterol and possibly calcium or bilirubin (from the breakdown of red blood cells); Pigment gallstones are small dark brown or black stones which form when there is excess bilirubin in bile and are more common in individuals with liver cirrhosis, biliary tract infection and sickle cell anaemia; Primary bile duct stones which form in the bile ducts and not the gall bladder. These are rare.
The risk of developing gallstones may increase if there is excessive cholesterol and if there is incomplete or infrequent emptying of the gallbladder. If the gallbladder doesn’t empty completely or often enough, bile may become very concentrated leading to the formation of stones. This may occur in pregnancy. If there is too little fat in the diet or meals are skipped, gallbladder contractions are decreased which can keep the gallbladder from emptying frequently.
There is a tendency for gallstones to run in families. Other factors that increase the risk include Sex as women between the ages of 20 and 60 years of age are more than twice as likely as men to have gallstones. This is explained by the fact that the female hormone Oestrogen causes more cholesterol to be excreted in bile. Pregnancy, the use of birth control pills and hormone replacement therapy increase bile cholesterol levels and decrease gall bladder emptying; Body Weight as an increase in Body Mass Index (BMI) increases the risk of developing gallstones because there is an increase in cholesterol in the bile and a reduction in bile salts and gallbladder emptying even in moderately overweight individuals; Diet as low calorie, crash diets disrupt bile chemistry and may reduce the frequency of gall bladder contractions. Individuals who undergo bariatric surgery (gastrointestinal surgery to lose weight rapidly) are also at an increased risk; Age as the risk increases with age and Ethnicity as Native Americans and Mexicans have a very high incidence.
Gallstones are often discovered on routine tests or examinations such as ultrasounds and computerized tomography scans for other conditions. The possible signs and symptoms for this condition include chronic indigestion with symptoms of nausea, bloating and abdominal pain which may occur or worsen after eating foods high in fat; Sudden onset of intense or moderate pain in the upper middle or upper right side of the abdomen which may radiate to the back and shoulder blade lasting from 15 minutes to several hours signals a gallbladder attack; Nausea and vomiting which may also accompany a gallbladder attack. Gallstones can get trapped at the neck of the gallbladder leading to persistent pain which could last several hours and fever. They can also enter and block the common bile duct or pancreatic duct leading to pancreatitis which could be fatal. Bile duct obstruction may lead to jaundice (yellowing of the skin and the white of the eyes), clay coloured stools, fever, chills and dark urine. The presence of any of these symptoms requires immediate medical attention.
Diagnosis is based on history, physical examination and investigations such as blood tests for elevated bilirubin and abnormal levels of pancreatic and liver enzymes. Other diagnostic tests include Ultrasonography, Computerised tomography (CT) scan, Radionuclide scan (cholescinitgraphy, HIDA scan), Endoscopic retrograde cholangiopancreatography (ERCP) and Endoscopic ultrasound (EUS)
Complications of gallstones include Blockage of the common bile duct which usually leads to jaundice, upper abdominal pain and dark urine. There may be an associated fever indicating an inflamed gallbladder (cholecystitis) or an infected bile duct (cholangitis); Inflammation of the Pancreas may occur as a result of an obstruction of the common bile duct near the junction of the pancreatic duct which leads to its blockage. This blockage leads to the back-flow of pancreatic juices and enzymes causing a very painful, life threatening acute inflammation of the pancreas; Gallbladder Cancer as individuals with gallstones are more likely to develop cancer of the gallbladder. It is thought that the stagnation of bile chronically exposes the gallbladder to toxins. Gallbladder cancer is rare however.
Gallstones are treated when there are associated symptoms. The treatment modalities include surgical (the preferred mode of treatment) and non-surgical approaches. The surgical treatments include Laparoscopic Surgery where surgery is performed with the aid of a laparoscope which is a pencil-thin tube with its own miniature video camera. Small incisions are required and the surgeon inserts the laparoscope through a cannula (hollow tube). The video camera produces a magnified image on a monitor to guide the process which is performed by the insertion of instruments through other small incisions. There is less post surgical pain, less scarring and a shorter recovery period with this method; Open Surgery where a large abdominal incision is made. This is usually the option in severe and complicated cases. After surgery, the liver continues to produce enough bile to digest a normal diet and there may be an increase in the number of bowel movements.