What is Cholelithiasis?
Cholelithiasis, or gallstones, are hardened bits of digestive fluid that can develop in your gallbladder, a small organ positioned just below the liver. This organ stores a digestive fluid called bile which is sent into your small intestine. In the United States, gallstones are quite common, affecting 6% of men and 9% of women. However, most people with gallstones don’t show any symptoms.
If gallstones are found by chance in patients who don’t have symptoms, these individuals only have a 1 to 2% chance of developing symptoms or complications each year. Notably, if these gallstones are in an otherwise healthy gallbladder with no issues, they don’t usually need treatment, unless symptoms start to show. Albeit, about 20% of these symptom-free gallstones may eventually begin to cause sensory findings over a 15-year follow-up period. A few may even lead to more serious conditions like inflammation of the gallbladder (cholecystitis), bile-duct inflammation (cholangitis), gallstones in the common bile duct (choledocholithiasis), pancreas inflammation due to gallstones (gallstone pancreatitis), and even, though rarely, bile duct cancer (cholangiocarcinoma).
What Causes Cholelithiasis?
Gallstones are formed through three main channels:
* Too much cholesterol: Normally, bile, a substance produced by the liver, is able to break down all the cholesterol the liver creates. However, if the liver makes too much cholesterol, then the bile can’t dissolve it all. This leftover cholesterol can turn into crystals and get stuck in the mucus in the gallbladder, progressively forming a sludge. Over time, these crystals can grow into stones that block the gallbladder’s ducts, causing gallstone disease.
* Excess bilirubin: Bilirubin is a yellow pigment made during the breakdown of red blood cells. It’s released into bile by liver cells. Certain blood conditions can cause the liver to create too much bilirubin. Like with cholesterol, this excess bilirubin can also form gallstones.
* Not emptying the gallbladder effectively: If the gallbladder isn’t able to empty properly, the bile can become concentrated and form gallstones.
Types of gallstones vary based on how they’re formed. The most common are cholesterol gallstones, black pigment gallstones, and brown pigment gallstones. Cholesterol gallstones are the most common, making up 90% of cases.
Each type of gallstone has its own risk factors. For cholesterol gallstones, risk factors include obesity, age, being a woman, pregnancy, genetic factors, receiving nutrition intravenously, losing weight rapidly, and certain medications (like oral contraceptives, clofibrate, and somatostatin analogs).
Black and brown pigment stones make up about 2% of gallstones. They’re seen in people who break down a lot of hemoglobin. The pigment they contain is mostly bilirubin. Patients with cirrhosis, ileal diseases, sickle cell anemia, and cystic fibrosis are at risk of developing black pigment stones. Brown pigment stones are more common in Southeast Asians and are not usually seen in the United States. Risk factors for brown pigment stones include bile duct blockages and chronic infection of bile with bacteria.
Patients with Crohn’s disease and those with ileum disease (or if part of ileum is removed) are unable to absorb bile salts, which increases their risk of getting gallstones.
Risk Factors and Frequency for Cholelithiasis
Cholelithiasis, or gallstones, is a condition that affects around 6% of men and 9% of women. It’s especially common in Native American populations, but less so in Africa and Asia. The growing obesity problem may have contributed to an increase in gallstones.
Even though gallstones are quite common, more than 80% of people with gallstones don’t have any symptoms. However, each year, 1% to 2% of people who previously didn’t have symptoms will start experiencing biliary pain. Some of these people may also start having serious complications at a rate of 0.1% to 0.3% each year. These complications can include conditions like cholecystitis, choledocholithiasis, gallstone pancreatitis, or cholangitis.
Signs and Symptoms of Cholelithiasis
Gallstone disease is a health condition involving the formation of stones in the gallbladder. People with this disease often experience sharp pain in the upper right portion of the abdomen, along with nausea and vomiting – a condition known as biliary colic. This pain typically comes and goes and subsides within about 30 to 90 minutes. The pain is most often triggered by eating fatty meals and usually starts an hour after eating such foods. However, not everyone experiences a link between the pain and eating, and some people find that the pain occurs at night.
Biliary colic happens when the gallbladder contracts, pushing a stone into the gallbladder’s exit tube, which increases pressure and causes pain. When the gallbladder relaxes, the stones often fall back into it, easing the pain. Severe, constant pain can indicate inflammation of the gallbladder (acute cholecystitis), which usually happens when a stone gets stuck in the gallbladder’s exit tube causing inflammation. This condition, besides pain, can also cause fever and tenderness in the right upper part of the belly (Murphy’s sign).
If a patient with gallstones also has a fever, rapid heart rate, low blood pressure, or yellowing of the skin or eyes (jaundice), they might have developed a complication such as, cholecystitis, inflammation of the bile duct (cholangitis), pancreatitis, or other more serious conditions.
One such complication is choledocholithiasis, which occurs when gallstones block the tube (common bile duct) that carries bile from your liver to your intestine. This blockage increases pressure inside the liver and leads to jaundice.
Cholangitis is another complication that happens when the blocked bile becomes infected, causing an inflammation of the liver and bile ducts. This condition is often indicated by severe upper right belly tenderness, fever, and jaundice (Charcot’s triad). It is typically treated with surgery to remove the blockage and antibiotics to counter the infection.
Testing for Cholelithiasis
To assess for gallstones, doctors often prescribe several laboratory tests, including blood counts, kidney and liver function tests, blood clotting profiles, and enzyme tests involving lipase and amylase among others. Analysis of urine is another common test ordered.
Ultrasound scans are the primary tool used to confirm the presence of gallstones. With an accuracy of 84%, and a certainty of 99%, ultrasounds are regarded as better than other scanning methods for spotting gallstones. Remember, even general practitioners can use ultrasound scans accurately and reliably to diagnose or discount gallbladder disease. On an ultrasound image, gallstones appear as highly reflective structures inside the gallbladder, casting shadows behind them. The gallbladder might also contain a sludge, which unlike stones, doesn’t cast shadows.
If an ultrasound scan shows thickening of the gallbladder wall (more than 3 mm thick), fluid around the gallbladder, or a positive Murphy’s sign, then acute cholecystitis (inflammation of the gallbladder) could be suspected.
Ultrasounds can also measure the common bile duct’s width. If the measurements come out to be larger than expected for the patient’s age, this could indicate the presence of gallstones. The common bile duct’s normal width is about 4 mm for people below 40 years. After 40 years, this width can increase by 1mm per decade. After gallbladder removal surgery, a width of up to 10mm is considered normal.
Suppose an ultrasound fails to clearly confirm or deny acute cholecystitis. In that case, another type of scan, called a nuclear medicine cholescintigraphy or HIDA scan, may be used. This scan involves injecting a radioactive tracer into the patient’s vein, then tracking its progress through the liver and into the gallbladder over 4 hours. If the gallbladder is diseased, the tracer won’t show up there. This method has a high sensitivity and specificity in diagnosing acute cholecystitis.
However, CT scans don’t significantly improve the diagnosis of gallstones or inflammation of the gallbladder. They can, however, help determine if the common bile duct is dilated and identify problems in the pancreas or other possible causes of abdominal pain if the ultrasound scan rules out gallstones.
Other tests, such as endoscopic or magnetic retrograde cholangiopancreatography (ERCP/MRCP), can be useful in detecting jaundice and dilated common bile duct or suspected cholangitis. These tests, though, are generally conducted after an ultrasound scan has been done. ERCP is an invasive procedure that uses contrast dye but allows doctors to intervene if they find a problem. MCRP, in contrast, is a non-invasive test that doesn’t require contrast dye.
Treatment Options for Cholelithiasis
Gallstones can be managed in two ways, depending on whether they cause symptoms or not.
If gallstones don’t cause symptoms, patients are advised on how to spot signs of biliary colic, which is intense stomach pain, and when they should see a doctor again. If the gallstones aren’t causing complications, they can be treated with pain medication taken by mouth or given by injection in the emergency room or urgent care center once they are diagnosed and other possible diseases are ruled out. Patients should also get advice on their diet to prevent the problem from recurring and they should get an appointment with a general surgeon for a non-emergency procedure to remove the gallbladder using a laparoscope, a small, lighted tube. This is the current standard treatment for gallstones, and most patients don’t have to stay in the hospital overnight.
If a patient has symptoms and tests that suggest acute cholecystitis, an inflammation of the gallbladder, they usually need to be hospitalized, see a surgeon, and be given antibiotics through an IV. Patients with gallstones blocking the bile duct or pancreas, also need to be hospitalized and to see a gastroenterologist, a doctor who specializes in the digestive system, who may perform a procedure to get images of the bile duct or pancreas. If a patient has acute ascending cholangitis, a serious infection that spreads up the bile duct, they’re usually very sick and may have sepsis, a life-threatening response to infection. They may need intensive care and a surgical procedure to drain the infection in the bile duct.
One medical treatment uses a medication called ursodeoxycholic acid, but it’s not usually practical. It only works for small, cholesterol-rich stones, and it can take 9-12 months to dissolve the stone in half of the cases.
Another option is a procedure that uses shockwaves to break up gallstones that aren’t calcified, or hardened with calcium.
What else can Cholelithiasis be?
- Sudden inflammation of the pancreas (Acute Pancreatitis)
- Inflammation of the appendix (Appendicitis)
- Narrowing of the bile duct (Bile Duct Strictures)
- Growth of abnormal tissue in the bile duct (Bile Duct Tumors)
- A serious diabetes complication where the body produces high levels of blood acids (Diabetic ketoacidosis)
- Immediate treatment of stomach and intestinal inflammation (Gastroenteritis)
- Unusual, painful contractions of the esophagus (Esophageal spasm)
- Cancer in the gallbladder
- Acid reflux disease causing heartburn (Gastroesophageal reflux disease or GERD)
- Liver inflammation (Hepatitis)
- A digestive disorder affecting the large intestine (Irritable bowel syndrome)
- Cancer in the pancreas
- Inflammation of the pancreas, whether sudden or over time (acute or chronic Pancreatitis)
- Damage in the lining of the stomach, lower esophagus or small intestine (Peptic Ulcer Disease)
What to expect with Cholelithiasis
Research indicates that only half of those with gallstones experience symptoms. The risk of death following an elective, or planned, laparoscopic procedure to remove the gallbladder is less than 1%. On the other hand, emergency gallbladder removal can have higher death rates.
Other potential issues after the surgery might include stones still left in the bile duct, hernias at the incision site, and damage to the bile duct. A small number of patients may also experience pain after the gallbladder removal.
Possible Complications When Diagnosed with Cholelithiasis
There are various health issues that can occur in relation to the gallbladder and pancreas, such as:
- Pancreatitis
- Bile duct stones
- Acute cholecystitis
- Gallbladder empyema, a condition where pus gathers in the gallbladder
- Gallbladder necrosis, which involves the death of gallbladder tissue
- Gallbladder cancer
- Cholecystoenteric fistula, an abnormal connection between the gallbladder and the intestines