What to do about gallstones

Gallstones are one of the most common digestive problems treated in women.

More than 25 million people in the United States have gallstones, and 65% to 75% of them are women. Fortunately, for most people, gallstones are “silent” — they don’t cause major symptoms. When they do act up, there are effective ways to address the problem.

What are gallstones?

Gallstones begin with bile, a substance that helps with the digestion of fats and the absorption of certain vitamins. Bile is made in the liver and carried to the gallbladder, a small, pear-shaped organ that concentrates and stores it. The fat in food triggers the release of a hormone that causes the gallbladder to contract and release bile into the intestine.

Gallstones are solid lumps that develop when the stored bile crystallizes. Most are less than an inch in diameter, but they can be as small as a grain of sand or as large as a golf ball. Most gallstones are composed mainly of cholesterol. The rest — known as pigment stones — are made of calcium salts and bilirubin, a breakdown product of red blood cells.

Cholesterol stones form when liquid bile in the gallbladder contains more cholesterol than the bile salts can dissolve. Cholesterol stones may also develop if the gallbladder doesn’t contract and empty as it should. Pigment stones are associated with certain medical conditions, including liver disease, some types of anemia, and infection of the bile ducts.

Why are women at greater risk?

It’s the effect of female hormones. Estrogen increases cholesterol in the bile, and progesterone slows the emptying of the gallbladder. That may explain why the risk for women, relative to men, decreases with age. Before age 40, women are diagnosed with gallstones almost three times more often than men are (pregnancy, for example, increases the risk), but by age 60, their risk is just slightly greater. Estrogen therapy increases the risk, especially when taken as a pill rather than a patch. Oral contraceptive pills also increase the risk slightly, but only in the first decade of use.

Obesity is another risk factor because bodies with more fat produce more estrogen. Paradoxically, rapid weight loss also increases the risk, because very low-calorie diets interfere with bile production and therefore cause more crystallization of cholesterol. Gallstones are so common after weight-loss surgery that patients may be advised to have their gallbladders removed at the same time. Gallstones are also more likely to occur in people with diabetes or any condition that decreases gallbladder contractions or intestinal motility, such as a spinal cord injury. Finally, there’s some evidence for genetic vulnerability to gallstone formation.

What are the symptoms?

Most people who have gallstones don’t know it. Their gallstones stay silent and may only be discovered incidentally, through an ultrasound or CT scan performed for other reasons. Symptoms arise mainly when stones pass through a bile duct or obstruct it, causing biliary colic — better known as a gallbladder attack. These attacks occur when the gallbladder contracts (usually in response to a fatty meal) and presses the stones so as to block the gallbladder duct. The main symptom is pain, usually in the right upper or middle abdomen (just below the rib cage), which builds to greatest intensity within an hour and can persist up to several hours. It can be either sharp and knifelike or a deep ache; sometimes it radiates to the back or the right shoulder. There may also be nausea and vomiting. The pain subsides as the gallbladder relaxes.

A stone lodged in a duct can also cause more serious problems, including acute cholecystitis (inflammation of the gallbladder), pancreatitis (inflammation of the pancreas), or cholangitis (inflammation of the bile ducts in the liver). Any of these conditions can cause severe pain and other symptoms, including jaundice, high fever, chills, and vomiting. Treatment usually requires hospitalization and often surgical removal of the stone.

If you think you’re having a gallbladder attack, your clinician will probably order several blood tests and an abdominal ultrasound (after you fast for at least eight hours). Ultrasound is particularly helpful in diagnosing acute cholecystitis because it also picks up any thickening of the gallbladder wall and indicates the presence of fluid, which may suggest inflammation. Other diagnostic techniques include cholescintigraphy, a radioactive injection used to view a possible blockage of the cystic duct; magnetic resonance imaging (MRI) of the bile ducts; endoscopic ultrasonography, which introduces an ultrasound device through the mouth, esophagus, and stomach to the duodenum (the first section of the small intestine) to get images of the area; and endoscopic retrograde cholangiopancreatography, which uses a scope inserted through the mouth to the duodenum to view the biliary ducts.

How are gallstones treated?

Typically, gallstones are treated only if they cause symptoms. For recurrent gallbladder attacks, the most effective treatment is surgical removal of the gallbladder, or cholecystectomy. In the past, the standard procedure was surgery requiring a five-inch incision and a hospital stay of up to a week. This approach has largely been replaced by laparoscopic cholecystectomy, in which the gallbladder is removed with instruments inserted through small incisions in the skin. This procedure requires only an overnight hospital stay and a week of recovery at home. However, there’s a slight risk of injuring the bile ducts, and in a small percent of cases, the surgeon may have to switch to an open surgery with a larger incision because of complications.

You can easily live without a gallbladder. The liver produces enough bile for normal digestion. When the gallbladder is removed, bile simply flows directly into the small intestine through the common bile duct. When no food is present, loose stools may result, but you can treat that with a bile acid–binding medication, such as cholestyramine (Questran).

Medical options

If you can’t or don’t want to undergo surgery and your gallstones are small, one option is to take ursodiol (Actigall, Urso), a naturally occurring bile acid that helps dissolve cholesterol stones when taken by mouth two to four times a day. It’s also used to prevent the formation of gallstones in people who are losing weight quickly. Ursodiol dissolves only those gallstones made of cholesterol, and it may take several months before it has an effect.

Drug therapy is occasionally combined with lithotripsy, in which sound waves from outside the body are used to break gallstones into pieces that dissolve more easily or are small enough to safely pass through the bile duct. Unfortunately, stones are likely to recur after medical treatment.

How can I reduce my risk for gallstones?

There’s no proven way to prevent gallstones, but eating a well-balanced diet, maintaining a normal weight, and exercising regularly (at least 30 minutes a day most days of the week). Avoiding fatty foods won’t prevent or get rid of gallstones, but it may reduce the frequency of attacks.

Image: rob_lan/Getty Images

Gallstones: Symptoms, diagnosis and treatment

The gallbladder is a pear-shaped pouch that sits just below the liver. It collects bile, a fluid made to help with digestion, as it flows from the liver to the intestine through the bile ducts. Gallstones are hardened bits of bile that form inside the gallbladder.

Bile makes it easier for you to digest fat. It also contains some waste products, including cholesterol and bilirubin, a substance created when old red blood cells are destroyed.

Gallstones form when cholesterol or bilirubin particles cluster together into a solid lump. The stone grows in size as the bile fluid washes over it, much like a pearl forms inside an oyster.

Most gallstones don’t cause any symptoms or problems. Small ones can leave the gallbladder and its draining ducts, then pass out of the body through the intestines.

Gallstones can cause symptoms if they get caught in the narrow outlet of the gallbladder, or in the ducts that drain the gallbladder. After meals, especially meals high in fat, muscles in the wall of the gallbladder contract to help release bile into the intestines. It can be very painful if the gallbladder squeezes against a gallstone, or if a gallstone blocks bile from being released into the intestines.

More serious problems can develop if a gallstone gets into the drainage-duct system but doesn’t make it all the way through to the intestines. In this case, the stone can cause a blockage, causing a buildup of bile in the gallbladder or liver. Since the digestive tract is teeming with bacteria, blocked fluid can lead to a very serious infection. If a gallstone lodges low down in the draining ducts, it can also block drainage of digestive enzymes from the pancreas. This can lead to inflammation of the pancreas (pancreatitis).

Gallstones are very common. About 1 in 5 women and 1 in 10 men have a gallstone by age 60. They are more likely to happen to older people, those who are overweight, and those who suddenly lose weight. Women who have had multiple pregnancies, taken birth control pills, or took estrogen after menopause are also more likely to develop gallstones.

Symptoms

Eighty percent of people with gallstones do not have any symptoms and do not need treatment. When gallstones do cause symptoms, they include:

• abdominal pain, usually high in the abdomen and often on the right side (where the gallbladder is located). The pain can spread to the back. Pain from gallstones can be steady or come and go. It can last between 15 minutes and several hours each time it occurs.
• sensitivity to high fat meals. Fats trigger the gallbladder to contract and can worsen pain.
• unexplained belching, gas, nausea, or a general decrease in appetite.

Gallstones can sometimes cause more serious problems such as pancreatitis or infections in the gallbladder or bile ducts. These can cause fever, more severe abdominal pain, or jaundice (a yellow color of the skin or whites of the eyes).

Diagnosis

Most gallstones do not show up on regular X-rays, but they are seen easily with an ultrasound. Gallstones often don’t cause symptoms. If you have symptoms that may or may not be due to gallstones, it may be difficult for your doctor to know if the stones are causing your symptoms even if you they show up on an ultrasound or CT scan.

If a stone is blocking the movement of bile, an ultrasound might show widened bile ducts. Your doctor may also order blood tests to evaluate injury to the liver and pancreas.

Prevention

You are less likely to form gallstones if you avoid becoming overweight. If you are a dieter, try to avoid diets that cause you to lose weight very quickly, such as diets restricted to fewer than 500 calories daily.

Birth control pills and estrogen can increase the likelihood of gallstones. Consider avoiding these medications if you already have other risk factors for gallstones. Groups at high risk of gallstones include American Indians, Hispanics, people with sickle cell anemia and women who have had multiple pregnancies.

Treatment

Gallstones require treatment only if they are causing symptoms. Smaller gallstones sometimes float out of the gallbladder on their own and are eliminated from the body in feces. Gallstone attacks can also calm down on their own if the bothersome stones shift position within the gallbladder. Even when gallstone symptoms go away on their own, they return within two years in about two of three people.

Most people whose gallstones cause symptoms will continue to have symptoms until the gallbladder is removed, although medications or procedures to break up the stones may also be used.

Surgery

Surgical treatment for gallstones is highly effective. In most people, symptoms go away completely and stay away. The gallbladder is not a necessary organ and most people do not notice any digestive changes after it is removed. Sometimes abdominal pain or diarrhea develop after the gallbladder is removed, and additional treatment or changes in the diet are needed.

Removing the gallbladder is usually done with a minimally invasive (“keyhole) operation known as laparoscopic cholecystectomy. In this procedure, a surgeon makes one or more small openings in the abdomen. A camera, called a laparoscope, is placed into the abdomen through one of these openings. It lets the surgeon see what he or she is doing during the operation.

Using small instruments inserted into the abdomen through other small openings, the surgeon removes fluid and stones from the gallbladder to deflate it. The gallbladder can then be detached from the digestive system and removed through one of the openings.

People tend to recover very quickly from laparoscopic surgery because the surgical wounds are very small.

Open cholecystectomy can be a better option for gallbladder removal among people who have significant abdominal scarring from prior surgery or those who are very obese.

About 5% of the time, a surgeon starts a laparoscopic procedure but changes to an open cholecystectomy for technical reasons.

For stones caught in the common bile duct, an additional treatment called endoscopic retrograde cholangiopancreatography (ERCP) might be needed. A doctor uses miniature instruments attached to a camera at the end of a flexible tube called an endoscope. The endoscope is passed maneuvered from the mouth down the esophagus and into the intestine. The doctor can tug stones out of the bile duct, or can widen the lower part of the duct so they pass into the intestine on their own.

Medication

When surgery is not a good option, an oral medication known as ursodeoxycholic acid (Actigall) may help. It usually takes about six months to see results, and is effective only about half the time. Once the medication is stopped, gallstones are likely to return.

Other procedures

Two other ways to break up gallstones include:

• shockwaves (lithotripsy) to break apart the gallstones so they can pass out of the body on their own
• dissolving gallstones with chemicals injected directly into the gallbladder

Surgery is strongly preferred over these other treatments because stones are likely to form again if the gallbladder is not removed.

City Clinical Hospital No. 31 im. Academician G.M. Savelyeva – Pills or surgery?

The surgical treatment of gallstones has long been recognized as the most effective and safest. However, many still doubt it.

What worries our readers the most?

Doctor of Medical Sciences, Head of the Department of Hospital Surgery of the Russian State Medical University, surgeon of the City Clinical Hospital No. 31 of Moscow, professor Sergey Georgievich Shapovalyants

1) Why remove the gallbladder if only one small stone has formed in it?

– Small stones in this case do not mean a small problem. On the contrary, they often cause serious complications.

If large formations lead to bedsores and gallbladder ruptures, then small stones are insidious in their own way. They can easily move and penetrate the bile ducts.

Wandering through them, the stones reach the duodenum. There, sooner or later, they get stuck, blocking the outflow of bile. Because of this, mechanical jaundice occurs.

Moreover, an attack of acute pancreatitis may suddenly develop. In this case, an ambulance from a doctor is needed.

Therefore, small stones should not be ignored. Even if at least one is found, you need to act. To date, the only treatment for gallstone disease is surgery – removal of the gallbladder.

2) There is a method of dissolving stones with the help of medicines. Why not try it before going to the surgeon?

– Indeed, there are such preparations. But the difficulty is that they rarely completely dissolve the stones. As a rule, drugs only slightly reduce them. The stone doesn’t go anywhere, it just gets smaller. Whether this is good or bad is a big question. As we said above, small stones cause no less problems than large ones.

Moreover, drugs are only effective against cholesterol stones. If they have a lot of calcium, conservative methods are useless.

One more thing. The size of the stones should not exceed 2 cm. It does not make sense to dissolve larger formations. This will take too long. After all, the stone, on average, decreases by no more than 1 mm per month.

It is not worth spending months or even years on this procedure. After all, no one can give a 100% guarantee of a successful result. And the risk of starting a problem is quite high.

Use with extreme caution in people with other gastrointestinal disorders. It is impossible to dissolve stones with stagnation of bile, acute inflammatory diseases of the gallbladder and bile ducts, liver diseases, stomach and duodenal ulcers, and problems with the intestines.

In addition, this seemingly harmless method of dealing with gallstones has its own side effects. The most common is stool disorder. And given that conservative treatment is designed for a long period, then it is unlikely that it will be possible to “endure” unpleasant reactions.

The situation is not easy. On the one hand, the method of drug dissolution of stones is quite safe – no anesthesia, incisions, postoperative rehabilitation is needed. On the other hand, it has many limitations and is not very effective.

3) How effective is the method of crushing gallstones, because kidney stones are crushed?

– The analogy between kidney stones and gallstones is often used. But these are completely different diseases, each of which manifests itself and is treated in its own way. Bringing them to the same denominator is incorrect.

At one time, the method of crushing gallstones using extracorporeal lithotripsy was widely used. During the session, multiple shock waves were directed at the stone from the outside. As a result, it was broken up into fragments, which then independently exited through the bile ducts and intestines.

In fact, not everything went so smoothly. Large fragments could not pass through the duct, so they remained in the gallbladder. Most of the small ones left “their place of residence”. But some of them got stuck in the bile ducts, clogged them and disrupted the process of bile formation. Therefore, after such a procedure, sometimes it was necessary to urgently do an operation.

There is one more important nuance. Usually gallstones are even, smooth, adapted to the shape of the gallbladder. Outside the attack, as a rule, they are not felt in any way. But after crushing, fragments are formed, which can cause colic and other painful sensations.

Due to the impressive number of undesirable consequences, this method is practically not used today. And in some foreign clinics, it is generally prohibited.

4) Is it possible to remove only stones and leave the gallbladder?

– It is possible, but this method is now recognized as ineffective. There is an opinion that some people, especially young people, should not have their gallbladder removed. After all, it performs important functions in the body.

Proponents of this approach perform an operation during which a small incision is made in the gallbladder. Through it, gallstones are taken out. Then the bladder is sutured, and after two or three days, a satisfied patient returns home. Without stones, and with a preserved gallbladder.

But not everything is so simple. Approximately 2-3 months after such an operation, the disease begins to bother again. The percentage of her return of the disease at different intervals reaches almost 100%. The fact is that one of the prerequisites for the formation of stones in the gallbladder is its poor contractility. Bile stagnates in it, from which stones are then formed.

Another reason is the individual characteristics of the bile itself. With any diet, even the lightest, it concentrates and precipitates. In this case, the elimination of stones alone simply does not make sense. Finally, the problem can be solved only by the complete removal of the gallbladder.

5) What are the advantages of laparoscopic stone removal?

– For a long time, gallstones were removed by the usual abdominal method. But today, many large hospitals and clinics are switching to a simpler and safer technique – laparoscopy.

The whole operation is carried out through three or four punctures in the abdominal wall. A miniature optical system is inserted through them. With its help, the abdominal cavity is examined, and then the gallbladder is removed with special tools.

As a rule, this is where the patient’s troubles end. After a short period of adaptation, he will be able to forget about gallstone disease forever.

Moreover, the absence of a gallbladder will be almost imperceptible. Indeed, in fact, his “biological loss” occurred much earlier – even at the stage of stone formation. Even then, the gallbladder stopped working normally, and other organs took over its “duties”.

6) Quite often, after removal of the gallbladder, a person feels even worse than before the operation. Maybe she doesn’t need it at all?

– There is such a thing as postcholecystectomy syndrome. This is a deterioration in well-being after removal of the gallbladder. Most often this happens if the operation is performed at an advanced stage of the disease, when neighboring organs are involved in the process.

In this situation, only one thing can be said – do not take things to extremes. Do the operation as planned, and not when the “thunder strikes.” Then problems can be easily avoided.

There is another reason – insufficiently serious preliminary examination. Today, removal of the gallbladder is considered a technically simple procedure for doctors and easily tolerated by patients. Therefore, the range of preliminary tests is often limited to one ultrasound of the abdominal cavity. And this is extremely small.

To get a complete picture and find out the true cause of poor health, it is necessary to carefully examine not only the gallbladder, but also all nearby organs. It is necessary to carefully assess the condition of the bile ducts, pancreas, duodenum, right kidney, stomach.

Not all medical institutions are equipped for this. Therefore, it is better to contact large clinics and centers.

When stones are suspected, endoscopic bile duct ultrasonography is now used successfully. It is performed using a miniature ultrasound probe or endoscope, at the end of which is an ultrasound probe. If there are stones in the bile ducts, you first need to eliminate them, and only then take on the gallbladder.

Computed tomography can help examine the liver and pancreas. Many of the necessary details will tell a biochemical blood test. Of course, not everyone needs these studies. But if there are at least some doubts, they cannot be ignored.

It is a thorough examination before surgery that allows you to choose the right tactics for treatment, preparation and recovery period. After all, the goal of surgical manipulations is not just to remove the problem, but to make it the most comfortable way for the patient.

Treatment and removal of stones in the gallbladder (treatment of gallstone disease, surgery), stones in the gallbladder laparoscopy in Nizhny Novgorod in the clinic

Gallstone disease is a problem that worries a large part of the population. The main contingent of patients are people with overweight, impaired metabolic processes in the body, diseases of the biliary tract, associated with stagnation of bile in the gallbladder.

The occurrence of stones in the gallbladder is a process associated with the stagnation of bile, the precipitation of cholesterol crystals contained in it. Gradually, small crystals combine and form stones, which sometimes reach impressive sizes. Under the action of the contraction of the bladder, it is possible for the stone to pass through the ducts.

Not always the size of the stone allows it to pass freely, which often leads to obstruction of the duct, accompanied by the so-called hepatic colic – acute paroxysmal pain in the right hypochondrium, and jaundice may also occur.

A large, heavy stone that lies in the gallbladder can form a decubitus due to constant pressure, and subsequently perforate the wall of the gallbladder with the development of peritonitis. All these complications can be prevented if timely treatment of gallstone disease , namely, to remove stones from the gallbladder.

To make a diagnosis, various measures are required (blood tests, ultrasound, x-rays with and without contrast). In particularly difficult cases, it is possible to perform a diagnostic laparoscopy.

Gallbladder stones may not cause any symptoms at all, so it is important to consider this disease in the differential diagnosis.

Gallbladder stones – treatment, modern approach to the problem

Treatment of gallstones can be conservative (without surgery) or surgical. Many people are afraid to go for surgery, as it is associated, in their opinion, with a great risk to health. But they expose themselves to even greater risk by refusing surgery for gallstone disease. Conservative treatment of cholelithiasis is possible in the presence of stones, ideally 5 mm (size up to 15-20 mm is allowed).

We must not forget that getting rid of stones, but not curing the main cause of their occurrence, you can get a relapse of the disease. Therefore, a radical treatment for gallstones is removal of stones from the gallbladder along with it. The operation is called a cholecystectomy.

The classic option for the surgical treatment of gallstone disease is cholecystectomy with laparotomic access (that is, an incision on the anterior abdominal wall).

However, medicine does not stand still and because of its trauma, long recovery period and possible complications, the method fades into the background. The current alternative (and the “gold standard for gallstone surgery”) is laparoscopic cholecystectomy.

The advantage of such an operation for cholelithiasis is that not one large incision is made, but several small ones (5-10 mm in size), which significantly reduces tissue trauma. Trocars and an optical device are inserted into the abdominal cavity through the holes, which transmits the image to the screen.

In this way, the surgeon can examine the gallbladder as well as adjacent organs. Removal of stones from the gallbladder is not performed separately.

During the operation, the entire gallbladder is removed along with its contents using a special electric knife, which ensures a minimum of bleeding. The gallbladder is placed in a special plastic bag in order to remove it from the abdominal cavity without tearing it. This is the prevention of the development of bile peritonitis. Also, the use of such a bag allows at laparoscopy, gallbladder stones should be removed one by one if they are large and cannot pass through a small hole in the abdominal wall at the same time.

Surgery for cholelithiasis is a guarantee of successful recovery and adequate prevention of relapses.

Advantages of laparoscopic surgery for cholelithiasis:

• Early activation period of the patient
• Minimize trauma and reduce the risk of complications
• Fast and accurate operation

Treatment of stones in the gallbladder in Nizhny Novgorod

Removal of stones from the gallbladder is possible during a laparoscopic operation – cholecystectomy.