By Daniel Lindenberg, MD, PA –
More than 1 million Americans are diagnosed with gallstones (cholelithiasis) every year; they join the 25 million who already have the disorder. Most people with gallstones do not have symptoms and do not require treatment. In some cases, however, gallstones cause pain or other complications and must be treated, usually by removing the stones or the entire gallbladder.
The gallbladder is a pear-shaped sac-like organ with a muscular wall that is 3 to 6 inches long, located in the right upper side of the abdomen, under the liver. It is connected to the liver and intestine through small tubes called bile ducts. The primary purpose of the gallbladder is to store and concentrate bile, a greenish-brown fluid that is produced by the liver. Bile is needed to digest and absorb fatty foods, and to absorb important fat soluble vitamins A, D, E, and K.
Between meals, the gallbladder is relaxed and bile flows into the gallbladder, where it is stored and concentrated. Fatty foods in the small intestine cause the gallbladder to contract (squeeze) and partially empty into the intestine. A few hours later, the gallbladder relaxes and begins to store bile again.
WHAT ARE GALLSTONES?
Gallstones are solid, pebble-like collections that form inside the gallbladder. Gallstones may be as small as a tiny speck or as large as the gallbladder itself. The vast majority, however, are smaller than 1 inch and are one of two major types; cholesterol, accounting for 80% of gallstones in the United States; or pigment accounting for the remaining 20% of gallstones. Gallstone type is important since cholesterol stones are more likely to respond to non-surgical treatments than pigment stones.
GALLSTONES RISK FACTORS
Experts are not sure why gallstones develop. However, many people who have gallstones also have bile with an abnormally high concentration of cholesterol and/or calcium; there are a number of factors that increase the risk of developing gallstones:
• Sex – Gallstones are more common in women.
• Age – The risk of gallstones increases with age, especially after the age of 40.
• Heredity – Anyone with a family member who has experienced Gallstones are at increased risk.
• Use of medicines that contain estrogen (such as birth control pills)
• Frequent fasting
• Rapid weight loss (including patients who have surgical weight loss treatments)
• Lack of physical activity
• Diabetes mellitus
• Sickle cell disease
• Cirrhosis or severe scarring of the liver
• Certain medicines
Silent gallstones — the majority of people who have gallstones do not have symptoms; their stones remain “silent”. Silent gallstones are often found on an ultrasound or CT scan done for other reasons. Silent stones do not need to be treated since the first symptoms of gallstones are usually mild and there are risks involved in removing the gallbladder.
If you have silent gallstones, you should be aware of the initial symptoms of gallstone disease because you may need treatment if you develop symptoms:
Biliary Colic — Biliary colic, also known as gallstone pain or biliary pain, is the most common symptom of gallstones. It causes bouts of abdominal pain, often located in the right upper stomach, under the lower ribs. You may also experience nausea/vomiting, and pain in the right shoulder or back. Biliary colic often occurs when the gallbladder contracts in response to a fatty meal. This compresses the stones, blocking the opening. As the gallbladder relaxes several hours after the meal, the pain subsides. In some people, pain occurs without eating a recent meal. Once you have a first attack of biliary colic, there is a good chance you will have more symptoms in the future. Such recurrent symptoms are usually more severe and occasionally associated with complications.
Complications of Gallstones
Acute Cholecystitis — acute cholecystitis refers to inflammation of the gallbladder. This occurs when the gallstone has completely blocked the gallbladder. Unlike biliary colic, which resolves within a few hours, pain is constant with acute cholecystitis and often accompanied with a fever.
Acute cholecystitis is a serious condition that requires immediate medical treatment in a hospital setting. Treatment includes IV fluids, pain medicine, and sometimes, antibiotics. Surgery to remove the gallbladder is usually recommended during the hospitalization or shortly thereafter. If not treated, acute cholecystitis can lead to gallbladder rupture, a life-threatening condition.
Choledocholithiasis — can develop if one or more gallstones leave the gallbladder and block the area where bile exits. It may lead to:
• Jaundice, a yellow discoloration of the skin
• Acute cholangitis, an infection of the bile ducts that causes pain, chills, and fever. This requires prompt treatment, usually involving removal of the gallstone with a non-surgical procedure known as endoscopic retrograde cholangiopancreatography, or ERCP.
• Acute pancreatitis, which is sudden inflammation of the pancreas, leading to severe abdominal pain.
GALLSTONE DIAGNOSIS — there are two parts to diagnosing gallstones: determining if gallstones are present, and determining if gallstones are the cause of symptoms.
Gallstones are usually found using ultrasound, a painless test that uses sound waves to create an image of the gallbladder. An ultrasound is the most sensitive test with which to find gallbladder stones, but gallstones can also be seen on other imaging tests.
Having gallstones does not mean that the gallstones are the cause of your symptoms. Thus, other tests may be recommended if there is doubt about the relationship of the gallstones to your symptoms.
GALLSTONE TREATMENT — there are three general options for people with gallstones; the best option depends upon your individual situation.
• Expectant management: Do nothing, wait and watch.
• Surgical therapy: Remove the gallbladder and stones.
• Non-surgical therapy: Eliminate the stones while preserving the gallbladder
Cholecystectomy — Cholecystectomy is a surgery that removes the gallbladder. It is one of the most commonly performed surgeries in the United States. The surgery is performed under anesthesia. In most people, the surgery is done using small instruments and a video camera, which are inserted into the abdomen through several small puncture holes. This is called laparoscopic cholecystectomy.
The gallbladder is an important organ, but you can live without it. Removing the gallbladder does not usually cause serious complications. However, about half of people who have their gallbladder removed develop loose stools, gas, and bloating; in most people these symptoms are mild, do not require treatment, and improve with time.
Non-Surgical Treatments — nonsurgical treatments are available for some people with gallstones, mainly those who cannot undergo cholecystectomy. These treatments get rid of the gallstones while preserving the gallbladder. The main disadvantage is that the stones can come back over time.
Bile Acid Pill – A bile acid pill (ursodeoxycholic acid or ursodiol) is a medicine that can dissolve and break down the cholesterol type of gallstones. 2/3 of people who take bile acid medication become symptom free within 2-3 months after starting treatment. However, it may take several years for the stones to disappear completely. The treatment is safe and well tolerated. Some people develop mild, temporary diarrhea. Because of its slow action, bile acid treatment is not practical in people who are having recurrent gallstone symptoms.
Extracorporeal Shock Wave Lithotripsy (ESWL) — ESWL is widely used for kidney stones but has fallen out of favor for the treatment of gallbladder stones. Only a few centers worldwide continue to offer it. It uses shock waves to break gallstones into smaller fragments and “sand,” which can then be dissolved more easily with an oral bile acid pill. It is most effective in people who have a normal body weight, fewer than three stones, and who have good gallbladder function. The procedure may be uncomfortable, a sedative can be given to reduce discomfort, and occasionally it may cause attacks of biliary pain as broken stone fragments pass through the bile duct.
Since bile acid therapy is needed to clear the fractured stones and residue, lithotripsy is mostly used to treat cholesterol stones. The success of lithotripsy for gallstones varies, with experienced centers successfully treating 90% to 100% of people with one stone and up to 67% of people with two or three stones.
Gallstone Recurrence — the main disadvantage of the non-surgical treatments is that gallstones can come back since the gallbladder is still in place. With bile acid treatment, stones come back in about 50% of people in the first five years. However, symptoms do not always come back and retreatment is not always needed. After cholecystectomy, gallstones may recur in the bile duct in a small percentage of patients.
Gallstone Prevention — To prevent gallstones from reoccurring maintain a healthy body weight by eating an appropriate number of calories and exercising for at least 30 minutes five days/week. If you are planning a rapid weight-loss program, such as weight loss surgery, you should be monitored by a doctor. Bile acid pills may be recommended to prevent gallstones from developing as you lose weight.
If you think you of a loved one are experiencing symptoms of Gallstones it is important to seek the attention of a qualified Gastoenterologist for more information about Gallstone screening and testing contact Dr. Lindenberg 561-316-6120.