What are gallstones?
Gallstones are small stones of varying size, which form in the gallbladder,
a small sac that lies under the liver.
The function of the gallbladder is to
store bile, a greenish-brown liquid produced by the liver.
During the digestion of food, the gallbladder contracts and bile passes
down the bile duct into the upper part of the bowel.
Gallstones may also pass from the gallbladder into the bile duct. This
involves passage through the cystic duct, a narrow tube that joins the
gallbladder to the bile duct.
Why do gallstones form?
There is no simple answer to this question.
In some people, the liver produces too much cholesterol and this can
result in the formation of cholesterol crystals in bile, which grow
into stones.
In others, gallstones form because of changes in other components of
bile or because the gallbladder fails to empty normally.
Gallstones become more common with advancing age and can be found in
up to 15% of senior citizens. They are more common in women than men,
with 20-30% of females developing gallstones by the age of 60.
There are other risk factors for the development of gallstones including
obesity, rapid loss of weight, cirrhosis, and some disease processes
involving the bottom section of the small intestine.
What symptoms do gallstones cause?
Only about three out of every ten patients who have gallstones will
experience symptoms.
Both gallstones and indigestion are common and one has to be careful
not to blame all indigestion-type symptoms on the presence of gallstones.
If gallstone symptoms develop, the patient is likely to experience
one of the following:
Colic:
Gallbladder contraction after heavy meals in a patient with gallstones
can result in an intermittent, often severe, pain which is experienced
in the upper, middle or right hand side of the abdomen or even in the
right shoulder and sometimes under the breast bone. These colicky attacks
will last for several minutes to several hours. They frequently will
occur at night.
Gallbladder Inflammation:
Occasionally the stones in the gallbladder can irritate the gallbladder
causing acute inflammation. In this condition, the pain is usually more
long lasting and tends to be more often in the right side of the abdomen.
Fever is often present and the patient is usually tender below the rib
cage on the right hand side.
Jaundice:
When a gallstone leaves the gallbladder and gets caught in the bile
duct, this will block the flow of bile from the liver and cause the
patient to become yellow or jaundiced. The urine will often turn dark
in colour and the stool becomes lighter in colour.
How are gallstones diagnosed?
The first investigation is usually an ultrasound study. This test is
relatively simple, free of side effects and is highly accurate for showing
stones in the gallbladder. In this test, sound waves are beamed into
the gallbladder and if there are stones present, the wave is reflected
back (echoed) to the machine which picks up and documents this echo.
Another test that can be used includes
a radionuclide bile duct scan where a small amount of radioactive
material
is injected into the vein. It is then concentrated by the gallbladder.
An agent (often a fatty meal) is then given to cause the gallbladder
to contract and empty.
Additional investigations may be required for people with serious
complications or those who are thought to have stones in the bile
duct. For example,
a flexible tube (endoscope) test called endoscopic retrograde cholangiopancreatography
(ERCP) may be required to demonstrate and remove bile duct stones.
In
this test, an endoscope is passed through the oesophagus and stomach
into the bowel and x-rays are taken after dye is injected into the
bile
duct.
What treatment options are available?
If you do have gallstones and are experiencing colicky pain, it is
best to avoid large meals and especially fatty foods and oils.
If you are overweight, then weight loss is certainly recommended. However,
if you have symptoms, these dietary manipulations are rarely enough.
Effective treatment of the gallstones usually involves one of the
following choices:
1. Watchful waiting
This is the preferred treatment if the gallstones are not causing symptoms.
Only in very special circumstances are gallbladders removed surgically
if there are no symptoms.
2. Laparoscopic surgery
This technique is now the treatment of choice for most patients with
gallstones.
A tiny incision is made through the navel and a micro video tube is
inserted through it. Other needle-like instruments are then inserted
through the upper abdomen and the gallbladder is picked up and dissected
and together with the stones, is teased out of the small incision. With
this surgery, the patient is often discharged the following day.
3. General surgery
This is sometimes necessary and does involve a 6-15cm incision in the
right upper abdomen and a stay in hospital of 4-6 days or more. This
operation
may be necessary in some patients because of technical problems with
the laparoscopic surgery.
4. Dissolving gallstones
As the gallbladder is usually functioning poorly, removal of the gallstones
and leaving the gallbladder frequently results in gallstone recurrence.
Drugs have been produced which can, in certain selected patients, dissolve
gallstones. This approach however, is now only rarely considered.
5. Gallstone shattering
Gallstones and kidney stones can be shattered using a machine (lithotripter).
This machine generates shock waves outside the body.
This technique is also only suitable for certain patients and is more
successful for kidney stones than for gallstones.
In general
• Concoctions of oils, biliary lubricants and “cleansers”
are sometimes used by alternative practitioners. There is no evidence
in a scientifically validated trial that these treatments work.
• The body can function quite well without a gallbladder although
diarrhoea can occasionally be troublesome and even more rarely, upper
abdominal discomfort can occur after the gallbladder is removed.
• Approximately one in twenty patients will continue to have
episodes of gallstone-like pain and a lot of these patients are subsequently
found to have irritable bowel syndrome.
• The correct treatment for each patient depends upon the gallbladder
symptoms, the patient’s age and the presence or absence of other
medical and non medical factors. The decision as to the appropriate
course of treatment should be taken by both you and your doctor together.
Acknowledgements: GESA – the Gastroenterological Society of Australia
