Gallstone Disease

Gallstone disease, also known as cholelithiasis,is a very common digestive problem that affects more than 25 million Americans and results in more than 500,000 surgical procedures each year. While gallstone disease may go unnoticed in most people, it can be serious and painful.

Gallstones are collections of solid matter that generally form in the gallbladder. The gallbladder is a small sac-like organ located underneath the liver on the upper right side of the abdomen. Its primary purpose is to store the bile that is secreted by the liver (up to three cups a day) and then deliver it to the small intestine to help break down food. During a meal, the gallbladder will contract and empty the bile through a series of small tubes, or bile ducts. Bile, which aids in fat digestion, is a fluid made up of mainly water, cholesterol, fat, bilirubin (the yellow-brown pigment) and bile salts.

Gallstones form when there is too much cholesterol or bilirubin in the bile. Small amounts of calcium are also usually present. The size and number of gallstones may vary greatly in different people. Some people may have only one stone; others can have several hundred. While most gallstones are about the size of a marble, they can be as small as a grain of sand or as large as a golf ball. Sometimes, only a sludge-like material will form.

Who Gets Gallstones?
Although no one knows for certain why some people form gallstones and others don't, we do know there are several potential risk factors.

Ethnicity: In general, people of Western European, Hispanic or Native American descent have a higher rate of gallstone formation than people of Eastern European, African or Asian descent.

Women: Women are much more likely to develop gallstones than men. Sex hormones, especially estrogen, appear to be a likely culprit. For example, women between the ages of 30 and 39 are three times more likely to develop gallstones than men in the same age group. But this disparity decreases with age. 
 In addition, women who are on estrogen replacement therapy or oral contraceptives seem to have a greater risk of gallstones, as do women who've given birth. In one study, gallstones formed in more than 12 percent of women who'd had children, compared with roughly 1 percent of those who had never given birth. Luckily gallbladder problems in new mothers commonly subside within one to two months of giving birth. Gallbladder sludge will resolve in two-thirds of women, and more than a third of small stones will disappear altogether.

Age: Age is also a major risk factor for both men and women. As we age, our chances of developing gallstones increase substantially, particularly after we hit age 60.

Obesity: Obesity is certainly a major risk factor as well. Even being moderately overweight increases your chance for forming gallstones.

Lack of physical activity: A study of more than 60,000 women showed that the risk of having gallstone disease is related to physical activity. Sedentary women were twice as likely as active women to need surgery for gallstones. Interestingly, this increased risk was not explained by higher rates of obesity among sedentary women – suggesting that exercise itself plays some protective role. Some studies of men have yielded similar findings.

Other risk factors: Rapid weight loss, family history of gallstone disease and certain medical conditions such as diabetes, cirrhosis of the liver, sickle-cell anemia and Crohn's disease can increase the risk of developing gallstones.

Gallstone Symptoms
Most people with gallstones have no symptoms. One study found that more than 80 percent of patients who had gallstones didn't exhibit any signs. Unfortunately, though, many people will eventually develop symptoms that cause discomfort and pain.

Typically, patients report attacks of pain in their upper-right or mid-abdomen. The pain is believed to stem from stones that are temporarily blocking the gallbladder duct. The pain is usually steady and builds in intensity over a 15- to 30-minute period. It remains constant for up to several hours before gradually disappearing. We do know that once you experience gallbladder pain, you're likely to get it again. Unfortunately, the timing and frequency of subsequent attacks is unpredictable.

Pain may also arise in the back, near the right shoulder blade. Nausea and vomiting may also occur. Unfortunately, your gallstone symptoms may not always be so obvious. Rather than having attacks of pain, you may experience a sensation of bloating after meals, indigestion or intolerance to particular foods, often fatty foods.

Other causes of upper abdominal pain
It is important to remember that pain in this area can be caused by other conditions. They range from simple indigestion to more serious problems such as an ulcers, liver or pancreas disorders or even heart disease. That is why a complete history and examination by a doctor is important.

Gallstone Complications
Cholecystitis
A gallstone can become impacted in the bile duct and lead to inflammation of the gallbladder. This is known as cholecystitis and can cause a fever and prolonged pain. Severe cases can result in serious, even life-threatening infection.

Cholangitis
Sometimes gallstones escape from the gallbladder but become lodged in the segment of the bile duct that connects with the small intestine, referred to as the common bile duct. The obstruction can be temporary or prolonged. A prolonged obstruction (usually more than several hours) can result in jaundice (yellowing of the skin) and pain. It can also lead to a severe, life-threatening infection, called cholangitis. If you have a fever in addition to jaundice and abdominal pain, you may be developing cholangitis, and it is important to see a doctor immediately.

Pancreatitis
Another complication of gallstone disease is pancreatitis, or inflammation of the pancreas. The pancreas is an organ that secretes digestive juices through the pancreatic duct, which empties into the same opening as the bile duct. If a gallstone becomes lodged in this opening and obstructs the flow of digestive juices, pancreatitis occurs. This can also be a severe, even life-threatening, condition that often requires hospitalization. Ironically, it is usually the small stones, or even gallbladder &gravel& or sludge, that may cause pancreatitis. Larger stones are likely to be too big to pass down the common bile duct.

Diagnosing Gallstones
There are a number of tests used to diagnose gallstones.

Ultrasound
If you have gallstone symptoms most often your doctor will order a test called an abdominal ultrasound or sonogram. This is a non-invasive test that uses sound waves, rather than x-rays, to create images. It is excellent for detecting gallstones and sludge. It is also useful in establishing whether the gallbladder is inflamed.

Cholecystogram
Another test for finding gallstones is an oral cholecystogram. This test involves taking an x-ray of your gallbladder after you swallow a pill containing radiographic dye. However, ultrasound is used more often since it is simpler to perform and does not involve exposure to radiation.

CT scan and x-ray
Occasionally, gallstones may be identified on a plain x-ray or by computerized tomography (CT scan), but these are much less sensitive than ultrasound for finding gallstones.

Endoscopic retrograde cholangiopancreatography and MRI
If your doctor suspects that a gallstone may be lodged in the bile duct, a technique called endoscopic retrograde cholangiopancreatography (or ERCP) may be used. This test is performed by a gastrointestinal specialist and involves swallowing a flexible tube that is moved to the area of the small intestine where the bile duct opens. X-ray dye is then injected into the bile duct, which enables the doctor to determine whether gallstones are present. If so, they can often be removed during this procedure.

If a stone in the common bile duct is suspected, your doctor may order a specific MRI, a magnetic resonance cholangiopancreatography, to detect it. It is a safer test, but if a stone is seen you may still need an ERCP to remove it.

Treatment Options
In general, if you have had more than one attack of gallbladder pain, you should be treated for gallstones. Their removal will save you from further pain and potential complications. However, there is some debate over whether patients should be treated after only one episode of pain, so discuss this with your doctor.

We currently have no evidence that treating someone without symptoms is beneficial. Therefore, we do not recommend a procedure known as prophylactic cholecystectomy, in which the gallbladder is removed after stones are found by chance. Possible exceptions to this recommendation include people who have a higher risk of developing complications from gallstone disease, like diabetics. Also, a surgeon may perform an &incidental cholecystectomy& during another abdominal operation, when appropriate.

Surgical options
In general, surgical removal of the gallbladder (cholecystectomy) is the treatment of choice for most patients.

Cholecystectomy: Until about 10 years ago, the open cholecystectomy was the standard operation. The surgery involves removing the gallbladder through a relatively large incision. While this is a safe procedure, it usually requires a four- to five-day stay in the hospital followed by two to three weeks of recuperation.

Laparoscopic cholecystectomy: Over the past decade, a less invasive approach to removing the gallbladder, called laparoscopic cholecystectomy, has become widely available. Typically, three 1-inch incisions are made, and a thin fiber-optic video camera and surgical instruments are inserted. This enables the surgeon to maneuver the instruments while watching a video monitor. There is much less damage to the abdominal muscles and surrounding tissue. As a result, you can expect less pain, a shorter hospital stay and a quicker recovery.

It is important to mention that not all patients can have the laparoscopic procedure. If the gallbladder is very inflamed at the time of surgery, it may be impossible to remove it this way. Additionally, if a gallstone has become trapped in the bile duct and your surgeon wishes to remove it at the time of surgery, it may be difficult to do so laparoscopically. Alternatively, your surgeon may wish to remove the gallbladder laparoscopically and have the bile duct stone removed non-operatively at a later time. Finally, there is a 5 percent chance that the laparoscopic procedure would need to be converted to an open procedure due to technical difficulties that the surgeon may encounter during surgery.

Complications: Injury to the bile duct appears to be significantly more common with the laparoscopic option. This occurs in 2 percent of patients, as compared to 0.1 percent of patients who have the open procedure. However, the overall complication rates for open and laparoscopic surgeries are similar, at about 5 percent.

Nonsurgical options
As mentioned above, gallstones that have been trapped in the common bile duct are generally removed by ERCP. During the procedure, a small cut, called a sphincterotomy, is usually made in the lower end of the bile duct using a heated wire that is threaded into the body through the endoscope. Stones can then be removed using a variety of balloons and baskets that are attached to catheters and snaked through the ERCP scope into the bile duct. For example, a balloon can be inflated to widen a narrowed area of the duct; afterward, a scaffold-like device called a stent may be inserted to maintain the dilation and allow normal drainage through the duct.

Most patients will also have the gallbladder removed to reduce the chance of having any future problems from gallstones; however, in special circumstances your doctor may advise against removing your gallbladder.

Lithotripsy
Lithotripsy is a technique that uses sound waves to fragment stones in the gallbladder or upper urinary tract. If you have severe medical problems that prevent surgery, and you have mild to moderate gallstone symptoms, your doctor may wish to try to dissolve the gallstones using medications or lithotripsy. If you have relatively few gallstones and they are not too large or composed of a lot of calcium, you may be a candidate for this therapy. Unfortunately, gallstones tend to reappear in about half of patients within three years. Lithotripsy for gallstone disease is less successful than when used for people with kidney stones. Ask your doctor which approach is best for you.

Conclusion
Gallstone disease is a very common condition, afflicting millions of Americans. Fortunately, most people with gallstones will remain free from symptoms. If you do have symptoms that are suggestive of gallstone disease, see your healthcare provider. Safe and effective treatment options are only a "stone's throw away."