Gallstones

Gallstones are stone-like masses that develop in the gallbladder.


Anatomy
The gallbladder is a small organ located beneath the liver on the right side of the abdomen. The gallbladder stores bile (a bitter-tasting fluid that helps the body digest fats) excreted from the liver and sends it to the small intestine during digestion. As bile is pushed from the gallbladder, it moves through the bile duct into the small intestine. If stones block any ducts that transport bile through the body, the bile can back up into the liver, gallbladder or bile ducts.

Causes/associated factors
Gallstones vary in size, from the size of a tiny grain of sand to a golf ball or any size in between. You may have a single gallstone or hundreds of them at once. Gallstones usually consist of cholesterol, bile pigments, calcium salts, water and bilirubin (a yellow pigment formed when red blood cells die; normally, bilirubin breaks down in the liver and leaves the body with the stool). Although the exact cause of gallstones is unknown, an increase in any of these components can cause gallstones to form. Left untreated, a blocked duct can cause severe or even fatal damage.
Gallstones are most common in women, older adults, Native Americans and Mexican Americans. A family history of gallstones, being obese, eating a high-fat diet, smoking and drinking alcohol excessively may also increase the likelihood of developing gallstones.

Other possible contributing factors include:

increased exposure to estrogen from pregnancy (especially multiple pregnancies) or medications, such as hormone replacement therapy or birth control pills
rapid weight loss and fasting
cholesterol-lowering medications
diabetes
recent illness, such as liver, intestinal or heart disease

Stages of gallstone disease
There are four stages of gallstone disease. First, you must have a gallbladder environment that's conducive to gallstone formation. Next, the stones form but cause no symptoms. Later, the stones may become lodged in a duct, which causes abdominal pain. The last stage is cholecystitis (a severe attack from an inflamed gallbladder). This condition can be fatal if not treated immediately.

Signs/symptoms
Depending on the stage of gallstone disease, symptoms may range from none at all to severe. When symptoms appear, they often develop suddenly in what's commonly called a gallbladder attack. These attacks often start during the night, often after eating fatty foods or a high-fat meal. Once an acute attack occurs, future attacks are likely. However, they may be weeks or even months apart.
Common symptoms of a gallstone attack include:

severe, quickly increasing abdominal pain in the upper right side that may last from 30 minutes to several hours
back pain between the shoulder blades
pain under the right shoulder
nausea or vomiting
abdominal bloating
belching, gas and indigestion
More serious symptoms that may indicate cholecystitis include:

sweating
shaking chills
low-grade fever
jaundice (yellowing of the skin or whites of the eyes; may be caused by a blockage of the bile passages or a liver disorder)
clay-colored stools

Diagnosis
To ensure proper treatment, an accurate diagnosis is critical. Give your doctor a detailed description of your symptoms. Then, you'll need a physical exam. You may also need a variety of tests.
Blood tests can help the doctor determine if you have an infection, obstruction or pancreatitis (inflammation of the pancreas, the gland that produces some of the enzymes the body needs to digest food).

The doctor may do an ultrasound (using sound waves to create images of internal body parts) to create a picture of the stone. Ultrasounds are often used to diagnose gallstones because they're highly accurate, noninvasive and low in cost.

With a cholecystogram, iodine is given in pill form. As the iodine collects in the gallbladder, a series of X-rays will help the doctor detect movement or obstruction.

With endoscopic retrograde cholangiopancreatography (ERCP), an endoscope (a thin, flexible tube equipped with a camera lens and light used to see the inside of a hollow organ or cavity) is placed down the throat to help guide the doctor toward the gallbladder. Then, the doctor will inject dye into the ducts to help locate any stones.

With a hepatobiliary scan (HIDA), also known as cholescintigraphy, a special nuclear substance is given intravenously and the gallbladder is screened with a monitor to help detect blockage in a duct.

Treatment
Depending on your individual circumstances, you may have a variety of treatment options. Discuss any concerns with your doctor before making a treatment decision. Make sure you understand the risks and benefits of each treatment method.
Watchful waiting
Treatment may not be necessary if you don't have any symptoms, unless the gallstones are more than 3 centimeters in diameter or the gallbladder has calcified (a condition known as porcelain gallbladder). About 30 percent of people will have a recurrence after an initial attack.

Watchful waiting benefits
Avoiding risks, costs and time associated with treatment.

Watchful waiting risks


Delaying treatment may not prevent complications.
Treatment may be required when you're older or in a more frail state.
A more serious condition, such as gallbladder cancer, may go undetected. Large gallstones and porcelain gallbladder cannot be left untreated as both conditions have been linked to gallbladder cancer.
Medication
Oral medication to dissolve gallstones may be a treatment option when surgery is not possible, you don't want to have surgery, or your condition is not an emergency. Medication therapy will depend on the condition of the gallbladder itself, as well as the size and composition of the gallstones (such as calcified, cholesterol or mixed types).

Ursodiol (Actigall, for example, also synonymous with ursodeoxycholic acid or UDCA) is usually prescribed for six months, but may be used for longer periods. Follow-up visits and testing, such as routine ultrasounds and blood tests, will help the doctor monitor whether the medication is working. If the stones are not at least partially dissolved after 12 months, the medication will probably not be successful. If you have pure cholesterol gallstones, bile salt therapy is considered most effective.

Medication benefits


Surgery and its risks are avoided.
In addition to dissolving gallstones, UDCA can help prevent gallstones that may form rapidly in people who lose a significant amount of weight quickly when treated for morbid obesity.
Medication risks


Treatment takes a long time.
Failure and recurrence rates are high (50 percent).
Side effects may include headache, dizziness, nausea, vomiting, diarrhea, constipation, back pain, urinary tract infection and rash.
Extracorporeal shock wave lithotripsy (ESWL)
Lithotripsy is a procedure that uses sound waves to crush the stones into smaller pieces so they can pass out of the gallbladder easier. Itotripsy. The procedure is not a treatment option if you have either a pacemaker or a serious hearbeat problem.

Lithotripsy benefits


Surgery and its risks are avoided.
The side effects are minimal.
Gallstones that are not calcified have nearly a 100 percent chance of dissolving.
ESWL is remarkably successful for the treatment of solitary gallstones.
Lithotripsy risks


The risks associated with anesthesia are present.
Passing the stones may require narcotic pain medication.
About 50 percent of people who are treated with ESWL experience recurrent gallstones within five years. Only 7.5 percent of the recurring stones cause symptoms, however.
About 1 percent of people who have the procedure develop pancreatitis (inflamed pancreas) due to a blocked bile duct.
Endoscopic retrograde cholangiopancreatography (ERCP)
Sometimes people develop stones that block the bile ducts. In these cases, ERCP is useful. With this procedure, the doctor uses an endoscope (a thin, flexible tube equipped with a camera lens and light) and X-ray to view the ducts of the pancreas and gallbladder. ERCP is most often used to look for gallstones or tumors, but it's also used to remove gallstones.

During the procedure, the endoscope is passed through the mouth into the stomach and small intestine. An X-ray machine called a fluoroscope guides the doctor during the procedure, and sedation helps prevent gagging. Medication is also given to relax the intestine. Dye is injected through the endoscope, and X-rays are taken in different positions while the endoscope is in place and after it's removed. A balloon or basket-type instrument may be passed through the endoscope to help the doctor grasp stones and carry them out. The balloon can be used to compress or widen the walls of the biliary tract to allow for improved bile flow.

ERCP benefits


The ducts of the gallbladder and pancreas can be seen, even when jaundice is present.
ERCP may be used in conjunction with surgery, most often to remove stones in ducts before the gallbladder itself is removed.
ERCP risks
ERCP carries a slight risk of infection, perforation of the intestines and organs, bleeding or urine retention (especially in men with prostate problems).

Solvent dissolution therapy
This is an experimental procedure in which the drug methyl-tert-butyl ether is injected directly into the gallbladder to dissolve the stones.

Solvent dissolution therapy benefits


Surgery and its risks are avoided.
The dissolution rate for noncalcified cholesterol stones is close to 100 percent.
There are few side effects.
Solvent dissolution therapy risks


The technique is invasive and considered labor intensive.
The solvent needs to be used with caution due to its flammable and toxic properties.
Surgical treatment options
Gallbladder removal, the most common abdominal surgery in the Unites States, remains the treatment of choice for most people with symptomatic gallstones. If people have cholecystitis, the treatment includes antibiotics, pain relief, and hospitalization with an IV and no food or liquid intake by mouth, usually followed by surgery.

Laparoscopic cholecystectomy (removal of the gallbladder)
A laparoscopy is a surgical procedure used to examine the abdominal area. The procedure is typically done under general anesthesia. You'll lie slightly tilted with your feet higher than your head. This allows your abdominal organs to fall toward your chest, making it easier for the doctor to see the area in question. To help the doctor see the organs more clearly, a gas (such as carbon dioxide) may be pumped into your abdomen through a small needle.

Next, an instrument called a laparoscope is inserted through a small incision just below your naval (belly button). If necessary, special instruments can be passed through the laparoscope or through another small incision lower in the abdomen. Often, surgeons will obtain X-rays during the procedure to be certain a common duct stone is not present. After the procedure, the gas is released and the incisions are closed with a few stitches. The stitches may be covered with a small adhesive bandage. The procedure will probably take less than 30 minutes. You may need to spend the night in the hospital so that you can be monitored for any postoperative complications. The hospital stay may be longer if additional open surgery was needed. (For example, the surgeon may need to switch to an open surgery with a larger incision if an infection or scarring from a previous surgery is found.)

Laparoscopy benefits
Compared to conventional surgery, laparoscopy offers:

smaller abdominal incisions
shorter hospital stay, if it's necessary at all
quick recovery time
early return to normal activity
less surgical risk for obese patients
less postoperative pain
Laparoscopy risks
The risks of laparoscopy include:

puncturing an organ
infection
bleeding
perforation of one of the major arteries or veins in the abdomen
shoulder or chest pain after surgery due to unabsorbed gas
risks associated with general anesthesia
rarely, the need to convert to a traditional open surgery
Open cholecystectomy (removal of the gallbladder)
If the gallstones are large, an open cholecystectomy may be necessary. This procedure may also be used if the biliary tract is not clearly visible, there is excessive bleeding, or the bile duct or some other organ is injured and repair is not possible with a laparoscopic procedure. With open cholecystectomy, the gallbladder is removed through a larger incision than what's needed for a laparoscopic approach. Again, your surgeon may obtain special X-rays during the procedure to be certain a common duct stone is not present.

Open cholecystectomy benefits


The procedure eliminates existing gallstones and the chance for recurrence.
There's a low risk of injury to other organs, such as the common bile duct, vascular structures or the bowel.
Open cholecystectomy risks


There is a risk of infection and bleeding. The risk varies depending on whether the surgery is due to an emergency condition.
Coexisting medical illnesses, such as cardiovascular or cerebrovascular disease, may increase the risk of surgical complications.
An open cholecystectomy requires a longer hospital stay than laparoscopic gallbladder removal.

Complications
Gallstones may lead to inflammation of the bile duct, gallbladder or pancreas. Pressure, swelling or death of the gallbladder tissue may eventually perforate the gallbladder. Again, potentially dangerous infections also create complications. Also, people who have symptomatic gallstones have a higher rate of gallbladder cancer.

Pregnancy-specific information
Gallstones are common during pregnancy. Continued nausea or vomiting may indicate a gallbladder attack or other abdominal problem. Be sure to discuss any abdominal symptoms with your obstetrician. Depending on your symptoms, treatment may be postponed until the baby is born -- especially if you're not in any discomfort. If immediate treatment is necessary, open or laparascopic cholecystectomy is often done. This is usually preferable during the second trimester.

Senior-specific information
Older adults have a greater risk of developing gallstones. Talk to your doctor about any symptoms that may indicate gallbladder disease.

Prevention
It's unclear what can be done to prevent gallstones. Based on factors that may trigger gallstones, consider the following dietary and lifestyle recommendations:
Decrease your fat intake, and get plenty of dietary fiber.
Eat meals at regular intervals.
Drink plenty of fluids.
Exercise regularly and avoid obesity.
Consult your doctor before attempting to lose a large amount of weight, and avoid rapid weight loss.