Gallstones

Gallstones

Gallstones are solid, pebble-like formations that originate within the gallbladder. They can vary in size from as small as a grain of sand to as large as a golf ball.

Causes, Incidence, and Risk Factors

The formation of gallstones can be attributed to various causes. There are primarily two types of gallstones:

• Cholesterol stones, which are the most prevalent type. Contrary to what one might assume, these stones are unrelated to cholesterol levels in the blood.

• Pigment stones, which are formed from bilirubin. This type of stone can develop when red blood cells are being broken down (a process known as hemolysis), leading to an excess of bilirubin in the bile.

Gallstones are more frequently observed in women, Native Americans, Hispanics, and individuals over the age of 40. Additionally, gallstones may have a familial predisposition.

The following factors may increase the likelihood of developing gallstones:

• Undergoing bone marrow or solid organ transplantation
• Having diabetes
• Experiencing inadequate emptying of the gallbladder, a condition more prevalent during pregnancy
• Suffering from liver cirrhosis or biliary tract infections (which are associated with pigment stones)
• Having medical conditions that result in excessive bilirubin production by the liver, such as chronic hemolytic anemia (including sickle cell anemia)
• Rapid weight loss due to a very low-calorie diet or bariatric surgery
• Receiving long-term nutrition via intravenous feedings

Symptoms

Many individuals with gallstones remain asymptomatic. Gallstones are frequently detected incidentally during routine x-rays, abdominal surgeries, or other medical procedures.

However, when a large stone obstructs either the cystic duct or common bile duct (a condition known as choledocholithiasis), it can cause cramping pain in the upper middle to right abdomen, referred to as biliary colic. This pain typically subsides when the stone passes into the duodenum (the first part of the small intestine).

Common symptoms may include:

• Pain in the upper right or middle abdomen, which may be constant, sharp, cramping, or dull, and may radiate to the back or below the right shoulder blade
• Fever
• Jaundice (yellowing of the skin and whites of the eyes)

Other associated symptoms may include:

• Clay-colored stools
• Nausea and vomiting

It is imperative to consult a doctor if experiencing symptoms suggestive of gallstones.

Signs and Tests

Various tests are utilized to detect gallstones or inflammation of the gallbladder. These tests may include:

• Abdominal ultrasound
• Abdominal CT scan
• Endoscopic retrograde cholangiopancreatography (ERCP)
• Gallbladder radionuclide scan
• Endoscopic ultrasound
• Magnetic resonance cholangiopancreatography (MRCP)
• Percutaneous transhepatic cholangiogram (PTCA)

Additionally, blood tests such as bilirubin levels, liver function tests, and pancreatic enzyme levels may be ordered by your doctor.

Treatment

SURGERY

For individuals with asymptomatic gallstones, surgery is typically unnecessary unless symptoms develop. However, exceptions may apply for patients who have undergone weight-loss surgery.

Generally, patients experiencing symptoms will require surgery either immediately or after a brief observation period.

• Laparoscopic cholecystectomy is the most common surgical procedure employed. This minimally invasive technique utilizes smaller incisions, resulting in a quicker recovery. Patients often return home on the same day as surgery or the following morning.

• Open cholecystectomy, which involves gallbladder removal through a larger incision, was previously the standard procedure for uncomplicated cases but is now less frequently performed.

Endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy may be performed to identify or treat gallstones in the common bile duct.

MEDICATION

Chenodeoxycholic acids (CDCA) or ursodeoxycholic acid (UDCA, ursodiol) may be administered orally to dissolve cholesterol gallstones. However, this treatment may take several years to be effective, and recurrence of stones is possible after treatment cessation.

Rarely, chemicals may be infused into the gallbladder via a catheter to rapidly dissolve cholesterol stones. This approach is seldom used due to its complexity, potential toxicity of the chemicals, and the risk of stone recurrence.

LITHOTRIPSY

Electrohydraulic shock wave lithotripsy (ESWL) of the gallbladder was previously employed for select patients who were unsuitable candidates for surgery. However, due to the high rate of stone recurrence, this treatment is now rarely utilized.

Expectations (Prognosis)

Gallstones may develop in many individuals without causing symptoms, and the likelihood of experiencing symptoms or complications is relatively low. Following gallbladder surgery, the vast majority of patients do not experience symptom recurrence (provided that the symptoms were indeed caused by gallstones).