Gallstones

Posted in Disease Information

Introduction

Gallstones are small stones, usually made of cholesterol, that form in the gallbladder. In most cases they do not cause any symptoms.

However, if a gallstone becomes trapped in a duct (opening) inside the gallbladder it can trigger a sudden intense abdominal pain that usually lasts between one and five hours. This type of abdominal pain is known as biliary colic.

The medical term for symptoms and complications related to gallstones is gallstone disease or cholelithiasis.

Gallstone disease can also cause inflammation of the gallbladder (cholecystitis). This can cause persistent pain, yellowing of the eyes and skin (jaundice) and a high temperature (fever) of 38°C (100.4°F) or above.

In some cases a gallstone can move into the pancreas, causing it to become irritated and inflamed. This is known as acute pancreatitis and causes abdominal pain that gets progressively worse.

The gallbla

The gallbladder is a small, pear-shaped, pouch-like organ situated underneath the liver. The main purpose of the gallbladder is to store and concentrate bile.

Bile is a liquid that is produced by the liver, which helps digest fats. It is passed from the liver through a series of channels, known as bile ducts, into the gallbladder.

The bile is stored in the gallbladder and, over time, it becomes more concentrated, which makes it better at digesting fats. The gallbladder is able to release bile into the digestive system when it is required.

Treating gallstones

Gallstone disease is relatively straightforward to treat. The most widely used treatment is keyhole surgery to remove the gallbladder.

Doctors refer to this as a laparoscopic cholecystectomy. This type of surgery is generally safe with a low risk of complications.

There are several non-surgical treatments that can be used to break up gallstones, but they often return at a later date. So surgery is usually the preferred option where possible.

You can lead a perfectly normal life without a gallbladder. The organ can be useful but it is not essential. Your liver will still produce bile to digest food.

Why do I have gallstones?

It is thought that gallstones develop because of an imbalance in the chemical make-up of bile inside the gallbladder.

In most cases the levels of cholesterol in bile become too high and the excess cholesterol forms into stones.

You are more at risk of developing gallstones if you are:

• Overweight
• Female – women are 2-3 times more likely to be affected by gallstone disease than men
• 40 or over – most cases of gallstone disease first develop in people aged 40 or above
• A mother – women who have had multiple pregnancies have an increased risk of getting gallstone disease. It is thought that the hormonal changes that occur during pregnancy can increase cholesterol levels

Who is affected

Gallstones are very common. There’s a 1 in 50 chance of gallstones causing symptoms. Most people only experience biliary colic, but a minority of people go on to develop more troublesome symptoms or a complication.

Complications

Cancer of the gallbladder is a rare but serious complication of gallstones.

Another rare but serious complication of gallstones is known as gallstone ileus. This is where the bowel becomes obstructed by a gallstone. This can cause symptoms such as vomiting and constipation.

Outlook

Most cases of gallstone disease are easily treated.

Very severe cases can be life-threatening, especially in people who are already in a poor state of health. It is estimated that the chance of dying from gallstone disease is less than 1 in 175.

Symptoms of gallstones

The most common symptom of gallstone disease is biliary colic, which is caused when a gallstone temporally blocks one of the bile ducts.

Bile ducts are tube-like structures that carry bile from the liver to the gallbladder and then into the digestive system.

Biliary colic

Biliary colic is a sudden, intense pain that usually lasts for over an hour (although sometimes it can last just a few minutes). The pain can be felt in:

• The centre of your abdomen, below your breastbone and above your bellybutton
• The upper right of your abdomen, with the pain travelling towards your shoulder blade

The pain is constant, dull and is not relieved you go to the toilet, pass wind or are sick.

The pain can be triggered by eating fatty foods and it may wake you up during the night.

Biliary colic usually happens infrequently. After an episode of pain, it may be several weeks or months before you experience another episode.

In addition to the pain associated with biliary colic, a number of people also experience:

• Feeling sick
• Being sick
• Excessive sweating

Doctors sometimes refer to biliary colic as uncomplicated gallstone disease.

The progression of symptoms

If you do develop symptoms of biliary colic it does not necessarily mean you will go on to develop a more serious form of gallbladder disease such as acute cholecystitis or acute pancreatitis.

It is estimated that only around 1 in 20 people with biliary colic will then go on to develop more severe symptoms.

Doctors use three categories when describing gallstone disease:

• Gallstones without symptoms –  but asymptomatic gallstone disease
• Gallstones that cause episodes of abdominal pain (biliary colic)– uncomplicated gallstone disease
• Severe forms of gallstone disease – this is known as complicated gallstone disease

When to seek medical advice

If you think you may be experiencing episodes of biliary colic you should make an appointment with Dr. B C Shah.

You should seek immediate medical advice if you experience any of the following symptoms:

• Jaundice – yellowing of the skin and eyes
• Abdominal pain that lasts longer than eight hours
• A high temperature combined with chills
• Abdominal pain so intense that you cannot find a position to relieve it

Causes of gallstones

It is thought that gallstones develop because of an imbalance in the chemical make-up of bile inside the gallbladder. Bile is a liquid that is produced by the liver to help digest fats.

It is still unclear what leads to this imbalance but it is known that gallstones can form in two ways:

• There are unusually high levels of cholesterol inside the gallbladder and the excess cholesterol gradually solidifies to form a stone; four out of five gallstones are made up of cholesterol
• There are unusually high levels of bilirubin inside the gallbladder; bilirubin is a waste product produced when red blood cells are broken down – the remaining one out of five gallstones is made up of bilirubin

Who’s at risk?

Gallstones are more common in the following groups:

• Women, particularly those with a history of multiple pregnancies
• Obese people – people who are overweight with a body mass index of 30 or above
• People who are 40 years of age or over (the older you are, the more likely you are to develop gallstones)
• People with cirrhosis (scarring of the liver)
• People with the digestive disorders Crohn’s disease and irritable bowel syndrome (IBS)
• People with a family history of gallstones (around 1 in 3 of people with gallstones have a close family member who has also had gallstones)
• People who have recently lost weight, either as a result of dieting or weight-loss surgery, such as gastric banding
• People who are taking a medication called ceftriaxone, which is an antibiotic used to treat a range of infections, including pneumonia (lung infection), meningitis (infection of the layers of the brain) and gonorrhoea (a sexually transmitted infection)

Women who are taking the combined oral contraceptive pill or undergoing high-dose oestrogen therapy (which is sometimes used to treat osteoporosis, breast cancer and the menopause) also have an increased risk of developing gallstones.

Other possible risk factors

Having type 2 diabetes and a lack of exercise are also possible risk factors.  However, they have not yet been conclusively proven to increase your risk of developing gallbladder disease.

Diagnosing gallstones

Asymptomatic gallstones

Gallstones are often discovered by chance during investigations of unrelated conditions. They are commonly detected during:

• Blood tests
• Cholesterol tests
• Ultrasound scans

Occasionally, gallstones are detected during X-rays.

Symptomatic gallstones

When you visit Dr. B C Shah with symptoms of gallstones, he will ask you about the pattern of your symptoms so that they can assess whether you may have complicated gallstone disease.

For example, they will want to know whether you have experienced a high temperature of 38C (100.4F) or above, a rapid heartbeat and jaundice.

They may also carry out a simple test known as the Murphy’s sign test. You breathe in and your Dr. B C Shah gently taps your abdomen near the location of your gallbladder. If the tapping causes pain, it usually indicates that your gallbladder is inflamed.

A diagnosis of gallstones can be confirmed using an ultrasound scan. You may also be given a liver function test. This is a type of blood test that is used to assess the state of your liver. The test is used because, if gallstones have moved into your bile duct, the normal functioning of your liver will be disrupted.

If your symptoms suggest that you have uncomplicated gallstone disease, you will be given a referral for a routine ultrasound.

If your symptoms suggest that you have complicated gallstone disease, you may be admitted to hospital so that an ultrasound can be carried out as soon as possible.

Cholangiography

Once a diagnosis of gallstones has been confirmed, you may have a procedure called a cholangiography to obtain further information about the gallstones and the condition of your gallbladder.

A cholangiography uses a dye that shows up on X-rays. The dye will either be injected into your bloodstream so that it concentrates in your bile ducts and gallbladder, or inserted into your bile ducts using a flexible, fibre-optic camera (endoscope). This procedure is called endoscopic retrograde cholangiopancreatolography (ERCP).

After the dye has been introduced, X-ray images are taken. The X-rays will reveal any abnormality in your bile or pancreatic systems, such as an inflamed gallbladder or pancreas. If your gallbladder and bile systems are working normally, the dye will be absorbed through all the places that bile is meant to go (your liver, bile ducts, intestines and gallbladder).

If the dye does not appear in one or more of these places, it usually signifies that gallstones are causing an obstruction. By studying the X-ray images, the precise location of the gallstones can be identified.

Treating gallstones

In cases of gallstones with no symptoms, a policy of ‘watchful waiting’ is recommended. This means you will receive no immediate treatment, but you should look out for any worsening of your condition and report any symptoms to your Dr. B C Shah.

As a general rule, the longer you go without experiencing any symptoms, the less likely it is that your condition will worsen.

The treatment plan for uncomplicated gallstone disease will depend on the frequency and severity of your symptoms, and the effect they have on your quality of life.

If your symptoms are mild and infrequent, and your quality of life is largely unaffected, surgery is not usually recommended. You may be prescribed painkillers, which you can use to control the symptoms if you experience another episode of biliary colic.

Surgery to remove your gallbladder will usually be recommended if your symptoms are more severe and occur frequently, leading to a reduction in your quality of life.

Whenever possible, surgery is recommended for all cases of complicated gallstone disease.

Cholecystectomy

A cholecystectomy is the surgical removal of the gallbladder. There are two types of cholecystectomy:

• Laparoscopic cholecystectomy
• Open cholecystectomy

Laparoscopic cholecystectomy

The most widely used type of cholecystectomy is laparoscopic cholecystectomy, which is a type of ‘keyhole’ surgery.

During a laparoscopic cholecystectomy, the surgeon will make four small incisions (cuts), each about 1cm or less, in your abdomen wall. One incision will be made by your naval (bellybutton) and the other three will be made across your upper abdomen.

Your abdomen will be inflated with carbon dioxide gas that is passed through the incisions. Inflating your abdomen gives the surgeon a better view of your organs and more room in which to work.

Dr. B C Shah will pass an instrument called a laparoscope through one of the incisions. A laparoscope is a small, flexible tube that has a light source and a camera at one end. The camera transmits images of the inside of your abdomen or pelvis to a television monitor.

Dr. B C Shah will then pass small instruments down the laparoscope which can be used to remove your gallbladder and any gallstones. Once the procedure is complete, the incisions will be sealed.

The advantage of having a laparoscopic cholecystectomy is that, as only small incisions are made in your abdomen, you will not experience much post-operative pain. You should also recover quickly from the effects of the operation. Most people are able to return home either on the day of the surgery or the day after.

Open cholecystectomy

In some circumstances, a laparoscopic cholecystectomy may not be recommended. This may be due to technical reasons or safety concerns. A laparoscopic cholecystectomy may not be recommended if:

• You are in the third trimester (the last three months) of your pregnancy
• You are obese
• You have cirrhosis (scarring of the liver)
• You have a condition that affects your blood’s ability to clot (thicken), such as haemophilia

In these circumstances, an open cholecystectomy may be recommended. During this procedure, Dr. B C Shah makes a large incision in your abdomen and removes your gallbladder.

An open cholecystectomy is an effective method of treating gallstone disease, but it has a longer recovery time compared with laparoscopic cholecystectomy. Most people take about six weeks to recover from the effects of an open cholecystectomy.

Alternative treatments

A number of alternative treatments are available for people who are unable or unwilling to have their gallbladder removed.

However, many of these methods are only effective in a minority of people with gallstones (estimated at around 1 in 10). Therefore, if alternative treatments fail, you may still require surgery.

The alternative treatment methods for gallstones are described below.

Ursodeoxycholic acid

Gallstones that are made of cholesterol can sometimes be treated using a medication called ursodeoxycholic acid, which slowly dissolves gallstones.

Ursodeoxycholic acid is also sometimes prescribed as a precaution against gallstones if it is thought that you have a particularly high risk of developing them. For example, you may be prescribed ursodeoxycholic acid if you have recently had weight-loss surgery.

Ursodeoxycholic acid is taken orally (in tablet form), and a course of treatment can last up to two years.

To increase the effectiveness of the medication, eating a low-cholesterol diet may be recommended. Dr. B C Shah can give you more information about your diet.

Side effects of ursodeoxycholic acid are uncommon and are usually mild. The most commonly reported side effects are:

• Nausea
• Vomiting
• Itchy skin

The use of ursodeoxycholic acid is not usually recommended for pregnant or breastfeeding women.

Sexually active women should use either a barrier method of contraception, such as a condom, or a low-dose oestrogen contraceptive pill while taking ursodeoxycholic acid. Other types of oral contraceptive pills are not recommended because they can sometimes interact unpredictably with ursodeoxycholic acid.

Lithotripsy

Lithotripsy is a method of concentrating ultrasonic shock waves onto the gallstones in order to break them up into tiny pieces.

It is rarely used when other treatments are possible as there can be up to a 50% chance of symptoms returning within 5 years of treatment.

Dr. B C Shah will carry out the lithotripsy procedure will first use an ultrasound scan to determine the location of the gallstones. They will press a sensor against your abdomen, next to the gallstones, which will then deliver the ultrasonic waves onto the gallstones.

Once the gallstones have been broken up, they can be safely passed out of your body in your faeces (stools).

Complications of gallstones

Cancer of the gallbladder

Cancer of the gallbladder is a rare but serious complication of gallstones.

Having a history of gallstones is a major risk factor for developing gallbladder cancer. Approximately 80% of people who have cancer of the gallbladder also have a history of gallstones.

However, people with a history of gallstones have a less than 1 in 10,000 chance of developing gallbladder cancer.

If you have additional risk factors, such as a family history of gallbladder cancer, it may be recommended that your gallbladder be removed as a precaution, even if you only have asymptomatic gallstones (no symptoms).

The symptoms of gallbladder cancer are similar to those of complicated gallstone disease, including:

• Abdominal pain
• High temperature (fever) of 38C (100.4F) or above
• Jaundice (yellowing of the skin and eyes)

Gallbladder cancer can be treated with a combination of surgery, chemotherapy and radiotherapy.

Gallstone ileus

Another rare but serious complication of gallstones is known as gallstone ileus. This is where the bowel becomes obstructed by a gallstone.

Gallstone ileus can occur when an abnormal channel, known as a fistula, opens up near the gallbladder. Gallstones are then able to travel through the fistula and can block the bowel. Symptoms of gallstone ileus include:

• Abdominal pain
• Vomiting
• Swelling of the abdomen
• Constipation

A bowel obstruction requires immediate medical treatment. If it is not treated, there is a risk that the bowel could rupture (split). This could cause internal bleeding and widespread infection.

If you suspect that you have an obstructed bowel. Surgery is usually required to remove the gallstone and unblock the bowel. The type of surgery that you will receive depends on where in the bowel the obstruction has occurred.

Preventing gallstones

Many of the risk factors for gallstones, such as age and gender, are fixed and cannot be prevented.

However, from the limited evidence available, the most effective way of preventing gallstones is to make lifestyle changes, such as:

• Changes to your diet
• Losing weight (if you are obese)

Diet

Due to the role that cholesterol appears to play in the formation of gallstones, it is advisable to avoid eating fatty foods with a high cholesterol content.

Foods that are high in cholesterol include:

• Meat pies
• Sausages and fatty cuts of meat
• Butter and lard
• Cakes and biscuits

A low-fat, high-fibre diet is recommended. This includes plenty of fresh fruit and vegetables (at least five portions a day) and whole grains.

There is also evidence that regularly eating nuts, such as peanuts or cashew nuts, can help reduce the risk of developing gallstones, as can drinking alcohol in moderation (no more than 3-4 units a day for men and 2-3 units a day for women).

Losing weight

Being overweight, and particularly being obese, increases the amount of cholesterol that is in your bile, which in turn increases your risk of developing gallstones. You should, therefore, control your weight by eating a healthy diet and taking plenty of regular exercise.

However, avoid low-calorie, rapid weight-loss diets. There is evidence that they can disrupt your bile chemistry and increase your risk of developing gallstones. A more gradual weight-loss plan is recommended.