Gallstones, hard deposits that accumulate in the gallbladder, are a very common problem, and they affect more than 25 million people in the US. Gallstone disease or cholelithiasis can be both painful and very serious, but it's also treatable.
Definition & Facts
Gallstones are hardened particles of digestive fluid that form in the gallbladder. Most gallstones are made of cholesterol, though about 20% of gallstones are made of bilirubin, a bile-related fluid produced by the liver.
Gallstones vary dramatically in size and can be as tiny as a grain of sand or as large as a golf ball. Cholelithiasis is a chronic condition and gallstones may be present in the body for years without creating symptoms.
However, when gallstones stick in the biliary duct or pass out of the gallbladder they can cause a gallbladder attack, in which the patient experiences intense abdominal pain, nausea, and perhaps vomiting. Gallbladder attacks can last for several hours.
Symptoms & Complaints
This type of attack, known as biliary colic, generally lasts from 1 to 5 hours, though the abdomen may remain tender for hours after the attack subsides. If inflammation of gallbladder tissue is also involved, the attack is referred to as cholecystitis and is generally both longer lasting and more severe. Cholecystitis may include extremely intense pain that radiates to the arms, back, or shoulders, along with abdominal tenderness, bloating, fever, chills, and sweating that lasts for hours or even days.
Attacks typically happen after heavy meals and occur most often in the evening or during the night. If the gallbladder is seriously inflamed or infected, fever may persist after the attack subsides, and the patient may notice dark urine, light colored stools, and yellowing or jaundice of the eyes and skin.
Gallstones form when the gallbladder empties infrequently or incompletely, or when the bile produced by the liver is imbalanced and contains insufficient bile salts or too much cholesterol or bilirubin. Though it's not always clear why these conditions occur, statistics show that some people are at substantially higher risk. Women, adults over 40, American Indians, Mexican Americans, and anyone with a family history of gallstones have a greater chance of developing gallstones.
Obesity and related disorders such as metabolic syndrome, diabetes, and insulin resistance all increase the risk of developing gallstones, and diets that are high in carbohydrates and calories but low in fiber are associated with the condition.
Rapid weight loss caused by extremely low calorie diets or bariatric surgery may also increase the risk of developing gallstones, as do disorders such as Crohn's disease, which interferes with the normal absorption of nutrients. Cirrhosis or deterioration of the liver, severe hemolytic anemias like sickle cell anemia, and bile duct infections are also known to trigger the formation of pigment stones, the type gallstones made of bile component bilirubin.
Diagnosis & Tests
Blood tests and ultrasound imaging are generally the initial tools of choice for diagnosing gallstones. Blood tests can indicate the presence of infection and help rule out other conditions, and ultrasound is a painless, non-invasive, and highly accurate way of identifying gallstones, and can be performed without anesthesia.
If complications are suspected, complete diagnosis may also involve the use of MRIs which can show stones in the biliary system ducts, and CT scans, which can show infections and blockages. In some cases a hepatobiliary iminodiacetic acid, also known as a HIDA or hepatobiliary scan, may be needed to diagnose obstruction or abnormal contractions of the gallbladder.
Though it is only used infrequently, ERCP, or endoscopic retrograde cholangiopancreatography can be very useful in locating and sometimes even removing elusive gallstones. The ERCP technology is relatively invasive in comparison with the other methods typically used to diagnose gallstones.
Treatment & Therapy
The usual treatment for gallstones is cholecystectomy, or the complete removal of the gallbladder, and it is generally recommended for anyone who has had even a single gallbladder attack. More than 600,000 cholecystectomies are done each year in the US, making it one of the most commonly-performed surgical operations in the nation.
About 90% of gallbladder removals are done by laparoscopic cholecystectomy, a minimally invasive procedure in which a thin tube with a video camera on the end is inserted into a small incision in the abdomen. Guided by the camera, the surgeon locates and removes the gallbladder through another small incision. This type of operation requires general anesthesia but is often done on an outpatient basis. Full recovery takes about a week.
If the gallbladder is severely inflamed or infected, an open cholecystectomy with a 4 to 6 inch incision may be required. An open cholecystectomy may require several days in the hospital and full recovery can take a month or more. Nonsurgical treatments via oral medication that dissolve the stones or shock wave lithotripsy that crushes the gallstones are possible, but are only used if the patient cannot withstand surgery.
Prevention & Prophylaxis
People who have had bariatric surgery or who have lost weight very rapidly through ultra-low calorie diets should talk with their physicians about the risk of developing gallstones; in some cases medications like ursodiol (also known as ursodeoxycholic acid and marketed as Actigall®) can be useful in preventing gallstone formation.