What is Gallstones (Cholelithiasis)?
Gallstones, also known as cholelithiasis, are behind one of the most common digestive issues in the United States. They are mostly found in developed countries but can appear anywhere in the world. Gallstones are a long-term disease but can also trigger sudden diseases in the pancreas, bile ducts, liver, and digestive tract. In the United States, over 6.3 million women and 14.2 million men aged between 20 to 74 struggle with gallstones. Most people with gallstones don’t show any symptoms, but in 10% of cases, symptoms will show within five years, and in 20% of cases, symptoms will show within 20 years of identifying the gallstones. The likelihood of having gallstones increases with age. More than a quarter of women over 60 will have gallstones. The composition and causes of gallstones are varied.
An important thing to remember about gallstones is that they do not always cause symptoms. Sometimes, they might move near the entry of the cystic duct and block the flow of bile. This can cause the gallbladder to stretch, leading to sharp, cramping pain known as biliary colic. If the duct remains blocked for more than a few hours, it could inflame the gallbladder wall, a condition known as cholecystitis. In some cases, the gallstone might move into the bile duct, causing a blockage which can lead to yellowing of the skin (jaundice) and abdominal pain. People who have had gallstones for a long time may develop a condition where the gallbladder gradually becomes scarred and loses its normal function. The best way to diagnose gallstones is through an ultrasound scan. Treating gallstones depends on whether they are causing symptoms. However, the best practice for treating symptomatic patients is by surgically removing the gallbladder, a procedure called a laparoscopic cholecystectomy.
What Causes Gallstones (Cholelithiasis)?
Gallstones are lumps that form in the gallbladder when bile, a digestive liquid, doesn’t empty out completely. This leftover bile can turn into a thicker substance called sludge, which sometimes becomes a gallstone. Blocked bile ducts or growths can also cause gallstones. The most common cause is when cholesterol in the bile solidifies.
There are three more types of gallstones. The first is pigmented gallstones, which are black and result from the breakdown of red blood cells. The second type, mixed pigmented stones, is a mix of calcium substances like calcium carbonate or calcium phosphate, cholesterol, and bile. The final type is called calcium stones, which occur when serum calcium solidifies usually in those with too much calcium in their blood. People with this type often have kidney stones too.
Several factors can increase the risk of gallstones, including pregnancy, as the hormone progesterone slows down the movement of the gallbladder. Other risks include obesity, genetics, and certain medications. Being female, having metabolic syndrome, rapid weight loss, and prolonged fasting can also make gallstones more likely. Other medical procedures such as bariatric surgery and conditions such as Crohn’s disease or ileal resection are also risk factors.
Risk Factors and Frequency for Gallstones (Cholelithiasis)
Many people have gallstones without even knowing it, especially as they get older. This includes an estimated 14 million women and 6 million men aged 20 to 74 in the United States. Several factors can increase the likelihood of gallstones:
- Being overweight, particularly for women, due to higher cholesterol levels in bile.
- Losing weight drastically or fasting, which can lead to a condition known as biliary stasis.
- Having higher levels of estrogen, due to either being of reproductive age or taking birth control medication that contains estrogen.
- Having chronic illnesses such as diabetes that can lead to an increase in gallstones and reduced gallbladder function due to nerve damage (neuropathy).
Remember, as we age, the risk of developing gallstones increases. So, it’s always important to stay healthy and maintain a balanced lifestyle.
Signs and Symptoms of Gallstones (Cholelithiasis)
People with gallbladder-related issues usually experience pain in the upper right side of the abdomen after consuming greasy or spicy foods. This pain can often be accompanied by nausea and vomiting. The pain might also be felt in the upper part of the abdomen and may extend to the middle back or right shoulder blade area. A common physical finding during an exam is what’s known as a ‘positive Murphy’s sign’ – this is when the patient feels pain under the right side of the rib cage when they take a deep breath while the doctor presses that area. However, keep in mind that patients can go for months or even years without any symptoms and then suddenly discover they have gallstones.
Acute cholecystitis, which is an inflammation of the gallbladder, presents similarly, but usually with more intense symptoms. A symptom of a blocked bile duct due to a trapped gallstone could be jaundice, or yellowing of the skin and eyes. In cases where a patient shows signs of both jaundice and abdominal pain, a medical procedure is typically performed to remove the gallstone and avoid further complications. For example, one such complication may be ascending cholangitis characterized by upper right abdominal pain, a fever, and jaundice, also known as Charcot’s triad. If the condition progresses, it can lead to neurological changes and a drop in blood pressure, a state known as Reynold’s pentad. Another complication could be acute pancreatitis, with symptoms like pain in the middle of the upper abdomen and uncontrolled vomiting.
Testing for Gallstones (Cholelithiasis)
To diagnose gallstones and subsequent acute cholecystitis, the most reliable test is an ultrasound of the upper right portion of the abdomen. This test has a specificity rate, or accuracy rate, of about 90%. Depending on the ultrasound operator’s skills, stones as small as 2 mm and even sludge or polyps within the gallbladder can be detected.
Specific indicators of acute cholecystitis, as opposed to cholelithiasis (the presence of gallstones), on an ultrasound include a thickening of the gallbladder wall that’s greater than 3 mm, fluid around the gallbladder, and a positive reaction to the sonographic Murphy’s sign.
Though gallstones can also often be identified through CT scans and MRIs, these are not as effective in diagnosing acute cholecystitis. Routine x-rays can usually detect about 10% of gallstones due to their high calcium content.
When there is suspicion of a stone within the common bile duct based on the ultrasound, the next step is a specific type of MRI known as magnetic resonance cholangiopancreatography (MRCP). If a stone is found in the common duct through the MRCP, then the best test to confirm this, known as an endoscopic retrograde cholangiopancreatogram (ERCP), should be conducted by a specialist doctor, called a gastroenterologist.
An alternative method for diagnosing common bile duct stones, a percutaneous transhepatic cholangiogram (PTHC), is also useful when an ERCP is not possible.
Treatment Options for Gallstones (Cholelithiasis)
Removing the gallbladder, known as cholecystectomy, is the usual treatment for painful gallstones. This procedure is usually performed using a minimally invasive method known as laparoscopic surgery. However, if a laparoscopic procedure isn’t feasible or safe, a traditional open surgery method may be used instead.
It’s not recommended to remove only the gallstones because research indicates that they tend to come back within a year. For seriously ill patients, or those who may not withstand surgery well, a temporary tube known as a decompression cholecystostomy can be put in place to relieve symptoms until the patient is stable enough for surgery.
If there are stones in the common bile duct, they can be taken out before or after surgery, or even during surgery, using an ERCP (an endoscopic procedure) or PTHC (a percutaneous transhepatic procedure). If a condition known as ascending cholangitis occurs, it’s crucial to swiftly remove the blockage, again using ERCP, PTHC, or surgery, alongside prompt antibiotic treatment.
In cases where cholecystitis, or inflammation of the gallbladder, is not severe and the patient is not a good candidate for surgery, gallstones may be treated with medication. Ursodiol is a drug used with varying success in the hopes of dissolving the gallstones, however, studies have shown mixed results, with less than 50% of patients responding positively in some cases.
What else can Gallstones (Cholelithiasis) be?
- Appendicitis (inflammation of the appendix)
- Renal calculi (kidney stones)
- Cholangiocarcinoma (bile duct cancer)
- Bile duct stones (hard deposits in the bile duct)
- Acute pancreatitis (sudden inflammation of the pancreas)
- Peptic ulcer disease (sores in the stomach lining)
What to expect with Gallstones (Cholelithiasis)
Less than half of individuals with gallstones will actually experience symptoms. Currently, the death rate after a laparoscopic cholecystectomy, a surgical procedure to remove the gallbladder, is less than 1%. However, in emergency cases, this rate increases to 10% or more. Other potential complications from this surgery might include stones left in the bile duct, a hernia developing at the incision site, and ongoing pain in the upper right area of the abdomen.
Even though laparoscopic cholecystectomy has become the standard treatment for symptomatic gallstones, there has been a rise in injuries to the bile duct during surgery.
Possible Complications When Diagnosed with Gallstones (Cholelithiasis)
Complications from gallstones can take various forms including:
- Inflammation of the gallbladder, which leads to a condition called cholecystitis
- Blockage of the common bile duct, which can result in a bile duct infection and yellowing of the skin and eyes, a condition known as jaundice
- Blockage of the pancreatic duct, which may cause inflammation of the pancreas or pancreatitis
- Gallbladder cancer
Preventing Gallstones (Cholelithiasis)
Education for patients mainly involves teaching them to stick to a diet low in fat, the importance of regularly taking their medication, and explaining how their disease works. Regular check-ups to monitor their condition are also crucial. Additionally, they should understand possible surgical treatments that could become important in the future.