How do gallstones form in the biliary tract. What are the main types of gallstones based on chemical composition. Which factors contribute to the increasing prevalence of gallstone disease worldwide. How does gallstone prevalence vary geographically. What are the health-related and socioeconomic impacts of gallstone disease.

Understanding Gallstone Formation and Types

Gallstones are solid, pebble-like deposits that form in the biliary tract, primarily in the gallbladder. These concretions can vary in size and composition, leading to different types of gallstones. But how exactly do they form?

The formation of gallstones is a complex process influenced by various factors. In essence, they develop when there’s an imbalance in the composition of bile, a fluid produced by the liver to aid in digestion. This imbalance can lead to the crystallization and eventual formation of stones.

Types of Gallstones

There are three primary types of gallstones, categorized based on their chemical composition:

• Cholesterol stones: These are the most common type in developed countries, accounting for more than 85% of cases.
• Pigment (bilirubin) stones: These are less common and are typically associated with certain medical conditions.
• Mixed stones: As the name suggests, these contain a mixture of cholesterol and pigment.

Is there a difference in how these types of stones form? Indeed, there is. Cholesterol stones result from an oversaturation of bile with cholesterol, combined with accelerated crystal nucleation and impaired gallbladder motility. On the other hand, pigment stones form when bilirubin is excreted in excess into bile (black stones) or in association with bile duct infections (brown stones).

Global Prevalence of Gallstones: A Geographic Perspective

The prevalence of gallstones exhibits significant geographic variation worldwide. This disparity can be attributed to a combination of genetic, environmental, and lifestyle factors that differ across regions.

Prevalence in Developed Countries

In the United States, approximately 20 million people (15% of the population) have gallstones. The Third National Health and Nutrition Examination Survey (NHANES III) revealed interesting ethnic variations:

• Higher prevalence among Mexican-Americans compared to non-Hispanic whites
• Lower prevalence among non-Hispanic blacks
• Extraordinarily high prevalence in American Indians, particularly the Pima tribe from Arizona

In Europe, ultrasound studies have shown a prevalence ranging from 9% to 21%, with an incidence of 0.63 per 100 persons per year.

Prevalence in Asia and Africa

How does the prevalence in Asia compare to Western countries? In Japan, recent studies have documented a higher gallstone prevalence (10%) than previously reported, along with an increased proportion of cholesterol stones. South Eastern Asia, however, shows a lower prevalence, with most cases being brown pigment stones.

Africa presents an even more striking contrast, with gallstone prevalence rates being notably lower than in other regions. This geographical variation underscores the importance of genetic and environmental factors in gallstone formation.

The Rising Trend of Gallstone Prevalence

A concerning trend has been identified in recent years: the increasing prevalence of gallstones in many parts of the world. This trend has been observed through both necroptic and ultrasound studies in Europe and North America.

Why is this trend occurring? Several factors contribute to the rising prevalence:

1. Changes in lifestyle, particularly in industrialized countries
2. Increasing rates of obesity
3. Adoption of Western diets in developing countries
4. Aging populations
5. Improved diagnostic techniques leading to better detection

This upward trend is not limited to Western nations. Japan, for instance, has also documented an increase in gallstone prevalence and a shift towards a higher proportion of cholesterol stones.

Health-Related and Socioeconomic Burden of Gallstone Disease

While the prevalence of gallstones is increasing, the impact of gallstone disease (GD) on mortality has shown a different trend. In the United States, mortality rates for GD decreased significantly between 1979 and 2004:

• 56% decrease for gallstones as the underlying cause of death
• 71% decrease for GD as the underlying or other cause of death

This decline in mortality represents the greatest rate of decrease for any common digestive disease during this period. However, the morbidity rates and socioeconomic burden of GD remain substantial.

Morbidity and Complications

Although only about 20% of all gallstones are symptomatic or lead to complications, these cases result in significant clinical morbidity and high healthcare costs. Complication rates are influenced by various factors:

• Age: Higher rates in older individuals
• Ethnicity: Some ethnic groups are more susceptible
• Socioeconomic factors: Access to healthcare and lifestyle choices play a role

Economic Impact

The economic burden of gallstone disease is substantial. In the United States:

• GD is the second most expensive digestive disease, surpassed only by gastroesophageal reflux disease
• In 2000, GD was the most common inpatient diagnosis, with 262,411 hospitalizations
• In 2004, there were 1.8 million ambulatory care visits with a GD diagnosis
• Approximately 700,000 cholecystectomies are performed annually
• The healthcare costs of GD amount to about $6.5 billion per year, having increased by 20% over the last three decades

Similarly, in Germany, about 190,000 patients with GD undergo surgery each year, highlighting the widespread impact of this condition.

Risk Factors for Gallstone Formation

Understanding the risk factors for gallstone formation is crucial for prevention and management strategies. These factors can be broadly categorized into modifiable and non-modifiable risk factors.

Non-Modifiable Risk Factors

Certain risk factors for gallstones are beyond an individual’s control:

• Advanced age: The risk increases with age
• Gender: Women are at higher risk, particularly those who have been pregnant
• Heredity: Genetic factors play a significant role
• Ethnicity: Some ethnic groups have a higher predisposition

Modifiable Risk Factors

Several lifestyle and health-related factors can influence gallstone formation:

• Obesity: Excess body weight increases the risk
• Rapid weight loss: Paradoxically, losing weight too quickly can promote gallstone formation
• Diet: High-fat, high-cholesterol diets may increase risk
• Physical inactivity: Regular exercise may help prevent gallstones
• Certain medications: Some drugs can increase the likelihood of gallstone formation

For pigment stones, specific risk factors include chronic hemolysis and liver cirrhosis for black stones, and biliary infections or infestations for brown stones.

Genetic Susceptibility to Gallstone Disease

Genetic factors play a significant role in determining an individual’s susceptibility to gallstone disease. But how much of the risk can be attributed to genetics?

Twin studies have provided valuable insights into the genetic component of gallstone risk. These studies estimate that genetic susceptibility contributes about 25% of the total gallstone risk. This means that while genetics play a substantial role, environmental and lifestyle factors are equally, if not more, important in determining whether an individual will develop gallstones.

Specific Genetic Factors

Recent research has identified specific genetic variants associated with an increased risk of gallstone formation. One notable discovery is the role of variants in the cholesterol transporter ABCG5/G8. These variants may account for approximately one-third of the genetic risk for gallstone disease.

This finding underscores the complex interplay between genetic predisposition and environmental factors in the development of gallstones. It also highlights the potential for targeted prevention strategies based on genetic risk factors in the future.

The Interplay of Genetics and Environment in Gallstone Formation

Cholesterol gallstone disease results from the interaction between genetic susceptibility and “lithogenic” environmental factors. This interplay explains why some individuals with genetic risk factors develop gallstones while others do not.

Environmental factors that can interact with genetic predisposition include:

• Diet: High-calorie, high-fat diets can exacerbate genetic risk
• Obesity: Excess body weight can amplify the effects of genetic susceptibility
• Hormonal factors: Pregnancy and hormone replacement therapy can influence risk
• Metabolic disorders: Conditions like diabetes can interact with genetic factors

Understanding this interplay is crucial for developing effective prevention strategies. While we cannot change our genetic makeup, modifying environmental and lifestyle factors can significantly reduce the risk of gallstone formation, even in genetically susceptible individuals.

Emerging Trends and Future Directions in Gallstone Research

As our understanding of gallstone disease continues to evolve, several emerging trends and future directions in research are worth noting:

Personalized Risk Assessment

With advances in genetic testing and our understanding of risk factors, there’s potential for more personalized risk assessment and prevention strategies. This could involve genetic screening combined with lifestyle and environmental factor analysis to provide individualized risk profiles and prevention recommendations.

Novel Treatment Approaches

Research is ongoing into new treatment approaches for gallstone disease. These may include:

• Targeted therapies based on genetic profiles
• New medications to dissolve or prevent gallstone formation
• Minimally invasive techniques for stone removal

Global Health Initiatives

Given the increasing prevalence of gallstone disease worldwide, there’s a growing focus on global health initiatives. These may include:

• Public health campaigns to raise awareness about risk factors and prevention
• Efforts to improve access to diagnosis and treatment in developing countries
• Research into the impact of changing diets and lifestyles in different regions

Microbiome Research

Emerging research is exploring the potential role of the gut microbiome in gallstone formation. This could lead to new prevention strategies or treatments based on modulating the microbiome.

As research in these areas progresses, our approach to preventing, diagnosing, and treating gallstone disease is likely to become more sophisticated and effective. This evolving understanding holds promise for reducing the global burden of gallstone disease in the future.

The field of gallstone research continues to advance, offering new insights into this common yet complex condition. From understanding genetic susceptibility to exploring novel treatment approaches, ongoing studies are paving the way for improved management of gallstone disease. As we unravel the intricate interplay between genetics, environment, and lifestyle factors, we move closer to more effective prevention strategies and personalized treatment options. The global nature of this health issue underscores the importance of continued research and public health initiatives to address the rising prevalence of gallstones worldwide.

The Growing Global Burden of Gallstone Disease

Vol. 17, Issue 4 (December 2012)

Gallstones are formed in the biliary tract, mainly in the gallbladder. About 10-15% of gallstone patients have simultaneous gallbladder and common bile duct stones, whereas intrahepatic stones occur less frequently. According to the chemical composition, there are three major types of stones: cholesterol, pigment (bilirubin), and mixed stones.

Gallstone prevalence and chronological changes

There is a marked geographic variation in gallstone prevalence (Figure 1). In developed countries, more than 85% of gallstones are cholesterol stones. About 20 million people in the USA (15% of the population) have gallstones ¹. The Third National Health and Nutrition Examination Survey (NHANES III) indicated a higher prevalence in Mexican-Americans than in non-Hispanic whites, and a lower prevalence in non-Hispanic blacks ². An extraordinarily high prevalence was found in American Indians (specifically, the Pima tribe from Arizona) (Figure 1). In Europe, ultrasound studies revealed a prevalence of 9 – 21% and an incidence of 0.63/100 persons/year ³. A trend for increasing gallstone prevalence has been identified in Europe and North America by necroptic ⁴ and ultrasound studies ^{5, 6}.

Figure 1: Worldwide prevalence of gallstones in females based on ultrasonographic surveys (Stinton LM, Shaffer EA, Gut and Liver 2012,; 6: 172-187).

This trend has also been demonstrated in Japan. Here, a higher gallstone prevalence (10%) than that previously described as well as an increased proportion of cholesterol stones has been documented by the Japan Gallstone Study Group ⁷. In South Eastern Asia, the prevalence of gallstones (mostly brown pigment) is low. Gallstone prevalence rates are even lower in Africa.

Health-related and socioeconomic burden of gallstone disease (GD)

Mortality rates for GD decreased between 1979 and 2004 in the United States by 56% for gallstones as the underlying cause and by 71% for GD as the underlying or other cause (Figure 2). This was the greatest rate of decline for any common digestive disease in this time period ¹. The trend is not the same with respect to morbidity rates. Although symptomatic and complicated stones represent only 20% of all gallstones, they  lead to clinically relevant morbidity and complications as well as high costs of medical care. Complication rates are higher in older people and in some ethnic groups, and are also influenced by socio-economic factors ^{8, 9}.

Figure 2: Gallstones: age-adjusted rates of death in the United States, 1979-2004 (Everhart JE & Ruhl CE, Gastroenterology 2009; 136: 1134-1144) (with permission from Elsevier).

In the United States, GD is the second most expensive digestive disease only surpassed by gastroesophageal reflux disease. In 2000, GD was the most common inpatient diagnosis, with 262,411 hospitalizations and 2004, there were 1.8 million ambulatory care visits with GD diagnosis ¹. Every year about 700,000 cholecystectomies are performed in the United States ¹¹, and 190,000 patients with GD undergo surgery in Germany ¹². The health care costs of GD (~ 6.5 billion dollars/year) increased by 20% over the last three decades in the United States ¹.

Risk factors for gallstones

Cholesterol gallstones result from oversaturation of the bile with cholesterol, combined with accelerated nucleation of crystals and impaired gallbladder motility. Advanced age, gender and heredity are major risk factors for cholesterol lithogenesis (Table 1). Cholesterol GD results from the interaction between genetic susceptibility and “lithogenic” environmental factors. Based on twin studies, genetic susceptibility has been estimated to contribute about 25% of the total gallstone risk ^{13, 14}. Variants of the cholesterol transporter ABCG5/G8 may account for one third of the genetic risk ^{15, 16}.

Table 1: Risk factors for gallstone disease

Pigment gallstones form when bilirubin is excreted in excess into bile (black stones) or in association with bile duct infections (brown stones). The major risk factors for black stones are chronic haemolysis and liver cirrhosis, and patients with biliary infections or infestations are at risk  for brown stones.

Risk factors contributing to the increasing prevalence of GD

The GD prevalence is rising in the industrialized countries in Europe and America due to the changes in life style. A similar trend appears to be present in some developing countries. Apart from the aging of the population, key risk factors accounting for the increasing GD prevalence are environmental.

Obesity

Obesity is a major risk factor for cholesterol GD, due to the increased hepatic cholesterol synthesis (via increased HMGCoA reductase activity) and biliary cholesterol excretion. The risk is higher in women and very high in morbidly obese individuals. Multiple weight cycling and rapid weight loss (e.g. after bariatric surgery) enhance the gallstone risk.

An increase of the body mass index between 1980 and 2008 has been documented worldwide, with great variations in different countries. In 2008, an estimated 1.46 billion adults were overweight, and of these, 500 millions were obese ¹⁷. The most dramatic obesity epidemic has been observed in the United States: in 1990 no state had an obesity prevalence equal to or higher than 15%; while in 2010 obesity was present in more than 25% of the adult population in half of the country’s states ¹⁸.

Diabetes mellitus

Type 2 diabetes is associated with an increased risk for GD. An increased cholesterol secretion into bile and gallbladder stasis, due to neuropathy, may explain the higher proportion of gallstone carriers among diabetics. Due to population growth, urbanization, aging and the increasing frequency of obesity and sedentary lifestyle, diabetes will continue to be a major health problem in developed countries and a growing problem in developing countries ^{19, 20}. At the global level, the number of people with diabetes increased from 153 million in 1980 to 347 million in 2008 ¹⁹. Accordingly, the age-standardized adult diabetes prevalence rate was significantly higher in 2008 (9.8% in men and 9.2% in women) than in 1980 (8.3% and 7.5%, respectively).

Metabolic Syndrome (MS)

The association between GD and obesity is now recognized as part of the MS, which includes central obesity, high triglyceride and low HDL-cholesterol levels, glucose intolerance, and hypertension. Hepatic insulin resistance stimulates cholesterol secretion into bile and impairs bile acid synthesis, favoring gallstone formation ²¹. Hepatic insulin resistance is associated with GD even in non-diabetic, non-obese individuals ²². The prevalence of MS is increasing up to epidemic proportions in many developed countries.

Non-alcoholic fatty liver disease (NAFLD)

NAFLD is the hepatic expression of the MS. Gallstones are more frequent in NAFLD patients than in the general population ^{23, 24}, as NAFLD and cholesterol GD share common lifestyle and metabolic risk factors. The obesity epidemic will lead to an increased prevalence of NAFLD.

Dyslipidemia

Although there is no correlation between cholesterol gallstones and total cholesterol levels in blood, GD is associated with low  HDL-cholesterol and high triglyceride serum levels. Nearly all patients with hypertriglyceridemia have supersaturated bile, even if they are lean ²⁵.

“Western-type” diet

The change over time in gallstone prevalence suggests that there has been a similar change with respect to environmental risk factors. One of the main environmental exposures is nutrition. Chronic overnutrition with refined carbohydrates and reduced intake of dietary fibre might account for the increased cholesterol gallstone prevalence in Native Americans, European countries and urban centres in Eastern Asia (Japan). This increase is linked to obesity, slow intestinal transit, hypertriglyceridemia, and insulin resistance. Moderate alcohol consumption and coffee consumption seem to be protective factors for gallstone formation, or at least for the development of symptoms in gallstone carriers.

Decreased physical activity

Prospective studies have shown that sedentary behavior is associated with an increased risk of cholecystectomy, both in women and men ²⁶. On the contrary, regular exercise improves – alone or most pronounced in association with low calorie diet – the metabolic profile associated with obesity and cholesterol gallstones, decreasing the lithogenic risk.

Liver cirrhosis and chronic hepatitis C virus (HCV) infection

End-stage liver disease is a well-known risk factor for GD. About 25-30% of cirrhotic patients have gallstones. Pigment lithogenesis is favored by chronic haemolysis and changes of liver metabolism. Cholesterol gallstones are also frequent in liver cirrhosis, in particular in cirrhotic patients with chronic HCV infection or NAFLD. Chronic HCV infection was shown to be an independent risk factor for GD both in patients with liver cirrhosis ²⁷ and in chronic hepatitis ²⁸. The prevalence of liver cirrhosis in HCV-infected patients has increased significantly over the past years ²⁹. It will continue to increase, given the fact that the spread of HCV infection in the USA and Europe occurred mainly after the 1970s and long duration of infection is necessary for cirrhosis to develop.

Conclusions

Gallstones are highly prevalent in most developed countries, leading to high health care costs. In developing countries, there also exists a trend toward an increasing prevalence of the metabolic risk factors for GD. As long as the obesity and diabetes epidemics continue to spread around the world, an increase of gallstone prevalence rates is to be expected; and will parallel the aging populations in these countries.

References

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2. Everhart JE, Khare  M, Hill M, Maurer KR. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 1999; 117: 632-639.
3. Angelico F, Del-Ben M, Barbato A et al. Ten-year incidence and natural history of gallstone disease in a rural population of women in central Italy. GREPCO. Ital J Gastroenterol 1997; 29: 249-254.
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5. Aerts R, Penninckx F. The burden of GD in Europe. Aliment Pharmacol Ther 2003; 18/suppl.3: 49-53.
6. Stinton LM, Shaffer EA. Epidemiology of gallbladder disease: cholelithiasis and cancer. Gut and Liver 2012; 6: 172-187.
7. Tazuma S. Epidemiology, pathogenesis and classification of biliary stones (common bile duct and intrahepatic). Best Pract Res Clin Gastroenterol 2006; 20:1075-1083.
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9. Freeman J, Boomer L, Fursevich D, Felix A. Ethnicity and insurance status affect health disparities in gallstone patients. J Surg Res 2012; 175: 1-5.
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14. Katsika D, Grjibovski A, Einarsson C et al. Genetic and environmental influences on symptomatic GD: a Swedish study of 43,141 twin pairs. Hepatology 2005; 42:1138-1143.
15. Buch S, Schafmayer C, Volzke H et al. A genome-wide association scan identifies the hepatic cholesterol transporter ABCG8 as a susceptibility factor for human gallstone disease. Nat Genet 2007; 39,:995-999.
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19. Danaei G, Finucane MM, Lu Y, et al. National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants. Lancet 2011; 378(9785):31-40.
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22. Chang Y, Sung E, Ryu S, et al. Insulin resistance is associated with gallstones even in non-obese, non-diabetic Korean men. J Korean Med Sci 2008; 23: 644–650.
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24. Fracanzani AL, Valenti L, Russello M et al. Gallstone disease is associated with more severe liver damage in patients with non-alcoholic fatty liver disease. PLoS One 2012; 7: e41183.
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Gallstones – Wake Gastroenterology

What are gallstones? Gallstones form when liquid stored in the gallbladder hardens into pieces of stone-like material. The liquid, called bile, is used to help the body digest fats. Bile is made in the liver, then stored in the gallbladder until the body needs to digest fat. At that time, the gallbladder contracts and pushes the bile into a tube – called the common bile duct – that carries it to the small intestine, where it helps with digestion.

Bile contains water, cholesterol, fats, bile salts, proteins, and bilirubin. Bile salts break up fat, and bilirubin gives bile and stool a yellowish color. If the liquid bile contains too much cholesterol, bile salts, or bilirubin, under certain conditions it can harden into stones.

The two types of gallstones are cholesterol stones and pigment stones. Cholesterol stones are usually yellow-green and are made primarily of hardened cholesterol. They account for about 80 percent of gallstones. Pigment stones are small, dark stones made of bilirubin. Gallstones can be as small as a grain of sand or as large as a golf ball. The gallbladder can develop just one large stone, hundreds of tiny stones, or almost any combination.

The gallbladder and the ducts that carry bile and other digestive enzymes from the liver, gallbladder, and pancreas to the small intestine are called the biliary system.

Gallstones can block the normal flow of bile if they lodge in any of the ducts that carry bile from the liver to the small intestine. That includes the hepatic ducts, which carry bile out of the liver; the cystic duct, which takes bile to and from the gallbladder; and the common bile duct, which takes bile from the cystic and hepatic ducts to the small intestine. Bile trapped in these ducts can cause inflammation in the gallbladder, the ducts, or, rarely, the liver. Other ducts open into the common bile duct, including the pancreatic duct, which carries digestive enzymes out of the pancreas. If a gallstone blocks the opening to that duct, digestive enzymes can become trapped in the pancreas and cause an extremely painful inflammation called gallstone pancreatitis.

If any of these ducts remain blocked for a significant period of time, severe–possibly fatal–damage or infections can occur, affecting the gallbladder, liver, or pancreas. Warning signs of a serious problem are fever, jaundice, and persistent pain.

What causes gallstones?

Cholesterol Stones

Scientists believe cholesterol stones form when bile contains too much cholesterol, too much bilirubin, or not enough bile salts, or when the gallbladder does not empty as it should for some other reason.

Pigment Stones

The cause of pigment stones is uncertain. They tend to develop in people who have cirrhosis, biliary tract infections, and hereditary blood disorders such as sickle cell anemia in which too much bilirubin is formed.

Other Factors

It is believed that the mere presence of gallstones may cause more gallstones to develop. However, other factors that contribute to gallstones have been identified, especially for cholesterol stones.

• Obesity. Obesity is a major risk factor for gallstones, especially in women. A large clinical study showed that being even moderately overweight increases one’s risk for developing gallstones. The most likely reason is that obesity tends to reduce the amount of bile salts in bile, resulting in more cholesterol. Obesity also decreases gallbladder emptying.
• Estrogen. Excess estrogen from pregnancy, hormone replacement therapy, or birth control pills appears to increase cholesterol levels in bile and decrease gallbladder movement, both of which can lead to gallstones.
• Ethnicity. Native Americans have a genetic predisposition to secrete high levels of cholesterol in bile. In fact, they have the highest rate of gallstones in the United States. A majority of Native American men have gallstones by age 60. Among the Pima Indians of Arizona, 70 percent of women have gallstones by age 30. Mexican American men and women of all ages also have high rates of gallstones.
• Gender. Women between 20 and 60 years of age are twice as likely to develop gallstones as men.
• Age. People over age 60 are more likely to develop gallstones than younger people.
• Cholesterol-lowering drugs. Drugs that lower cholesterol levels in blood actually increase the amount of cholesterol secreted in bile. This in turn can increase the risk of gallstones.
• Diabetes. People with diabetes generally have high levels of fatty acids called triglycerides. These fatty acids increase the risk of gallstones.
• Rapid weight loss. As the body metabolizes fat during rapid weight loss, it causes the liver to secrete extra cholesterol into bile, which can cause gallstones.
• Fasting. Fasting decreases gallbladder movement, causing the bile to become overconcentrated with cholesterol, which can lead to gallstones.

Who is at risk for gallstones?

• women
• people over age 60
• Native Americans
• Mexican Americans
• overweight men and women
• people who fast or lose a lot of weight quickly
• pregnant women, women on hormone therapy, and women who use birth control pills.

What are the symptoms?

Symptoms of gallstones are often called a gallstone “attack” because they occur suddenly. A typical attack can cause:

• steady pain in the upper abdomen that increases rapidly and lasts from 30 minutes to several hours
• pain in the back between the shoulder blades
• pain under the right shoulder
• nausea or vomiting Gallstone attacks often follow fatty meals, and they may occur during the night.

Other gallstone symptoms include:

• abdominal bloating · recurring intolerance of fatty foods
• colic
• belching
• gas
• indigestion

People who also have the above and any of following symptoms should see a doctor right away:

• sweating
• chills
• low-grade fever
• yellowish color of the skin or whites of the eyes
• clay-colored stools

Many people with gallstones have no symptoms. These patients are said to be asymptomatic, and these stones are called “silent stones.” They do not interfere in gallbladder, liver, or pancreas function and do not need treatment.

How are gallstones diagnosed?

Many gallstones, especially silent stones, are discovered by accident during tests for other problems. But when gallstones are suspected to be the cause of symptoms, the doctor is likely to do an ultrasound exam. Ultrasound uses sound waves to create images of organs. Sound waves are sent toward the gallbladder through a handheld device that a technician glides over the abdomen. The sound waves bounce off the gallbladder, liver, and other organs such as a pregnant uterus, and their echoes make electrical impulses that create a picture of the organ on a video monitor. If stones are present, the sound waves will bounce off them, too, showing their location. Ultrasound is the most sensitive and specific test for gallstones.

Other tests used in diagnosis include:

• Computed tomography (CT) scan may show the gallstones or complications.
• MR cholangiogram may diagnose blocked bile ducts.
• Cholescintigraphy (HIDA scan) is used to diagnose abnormal contraction of the gallbladder or obstruction. The patient is injected with a radioactive material that is taken up in the gallbladder, which is then stimulated to contract.
• Endoscopic retrograde cholangiopancreatography (ERCP). The patient swallows an endoscope–a long, flexible, lighted tube connected to a computer and TV monitor. The doctor guides the endoscope through the stomach and into the small intestine. The doctor then injects a special dye that temporarily stains the ducts in the biliary system. ERCP is used to locate and remove stones in the ducts.
• Blood tests. Blood tests may be used to look for signs of infection, obstruction, pancreatitis,or jaundice.

Gallstone symptoms are similar to those of heart attack, appendicitis, ulcers, irritable bowel syndrome, hiatal hernia, pancreatitis, and hepatitis. So accurate diagnosis is important.

What is the treatment?

Surgery

Surgery to remove the gallbladder is the most common way to treat symptomatic gallstones. (Asymptomatic gallstones usually do not need treatment.) Each year more than 500,000 Americans have gallbladder surgery. The surgery is called cholecystectomy.

The most common operation is called laparoscopic cholecystectomy. For this operation, the surgeon makes several tiny incisions in the abdomen and inserts surgical instruments and a miniature video camera into the abdomen. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. While watching the monitor, the surgeon uses the instruments to carefully separate the gallbladder from the liver, ducts, and other structures. Then the cystic duct is cut and the gallbladder removed through one of the small incisions.

Because the abdominal muscles are not cut during laparoscopic surgery, patients have less pain and fewer complications than they would have had after surgery using a large incision across the abdomen. Recovery usually involves only one night in the hospital, followed by several days of restricted activity at home.

If the surgeon discovers any obstacles to the laparoscopic procedure, such as infection or scarring from other operations, the operating team may have to switch to open surgery. In some cases, the obstacles are known before surgery, and an open surgery is planned. It is called “open” surgery because the surgeon has to make a 5- to 8-inch incision in the abdomen to remove the gallbladder. This is a major surgery and may require about a 2- to 7-day stay in the hospital and several more weeks at home to recover. Open surgery is required in about 5 percent of gallbladder operations.

The most common complication in gallbladder surgery is injury to the bile ducts. An injured common bile duct can leak bile and cause a painful and potentially dangerous infection. Mild injuries can sometimes be treated nonsurgically. Major injury, however, is more serious and requires additional surgery.

If gallstones are in the bile ducts, the physician (usually a gastroenterologist) may use endoscopic retrograde cholangiopancreatography (ERCP) to locate and remove them before or during the gallbladder surgery. In ERCP, the patient swallows an endoscope–a long, flexible, lighted tube connected to a computer and TV monitor. The doctor guides the endoscope through the stomach and into the small intestine. The doctor then injects a special dye that temporarily stains the ducts in the biliary system. Then the affected bile duct is located and an instrument on the endoscope is used to cut the duct. The stone is captured in a tiny basket and removed with the endoscope. Occasionally, a person who has had a cholecystectomy is diagnosed with a gallstone in the bile ducts weeks, months, or even years after the surgery. The two-step ERCP procedure is usually successful in removing the stone.

Nonsurgical Treatment

Nonsurgical approaches are used only in special situations – such as when a patient has a serious medical condition preventing surgery – and only for cholesterol stones. Stones usually recur after nonsurgical treatment.

• Oral dissolution therapy. Drugs made from bile acid are used to dissolve the stones. The drugs, ursodiol (Actigall) and chenodiol (Chenix), work best for small cholesterol stones. Months or years of treatment may be necessary before all the stones dissolve. Both drugs cause mild diarrhea, and chenodiol may temporarily raise levels of blood cholesterol and the liver enzyme transaminase.
• Contact dissolution therapy. This experimental procedure involves injecting a drug directly into the gallbladder to dissolve stones. The drug – methyl tertbutyl ether – can dissolve some stones in one to three days, but it must be used very carefully because it is a flammable anesthetic that can be toxic. The procedure is being tested in patients with symptomatic, noncalcified cholesterol stones.

Don’t people need their gallbladders?

Fortunately, the gallbladder is an organ that people can live without. Losing it won’t even require a change in diet. Once the gallbladder is removed, bile flows out of the liver through the hepatic ducts into the common bile duct and goes directly into the small intestine, instead of being stored in the gallbladder. However, because the bile isn’t stored in the gallbladder, it flows into the small intestine more frequently, causing diarrhea in about 1 percent of people.

Points to Remember

• Gallstones form when substances in the bile harden.
• Gallstones are more common among women, Native Americans, Mexican Americans, and people who are overweight.· Gallstone attacks often occur after eating a meal.
• Symptoms can mimic those of other problems, including heart attack, so accurate diagnosis is important.
• Gallstones can cause serious problems if they become trapped in the bile ducts.· Laparoscopic surgery to remove the gallbladder is the most common treatment.

For More Information

To find more information on this topic, visit:

WebMD
MayoClinic.com

Cholelithiasis: symptoms, diagnosis, methods of treatment

Cholelithiasis is accompanied by formations in the gallbladder and bile ducts of stones of various origins. Stones are clots of cholesterol, calcium salts and bilirubin (bile pigment). One of the most common complications of gallstones is cholecystitis. Clots can form quite quickly – from one to several months. The optimal method of treatment is minimally invasive surgery: at Odrex, laparoscopic cholecystectomy is performed by surgeons with extensive experience in this operation, members of the European Association of Endoscopic Surgeons and participants in international conferences.

Causes of cholelithiasis

• Metabolic disorders,
• disorders of bile secretion,
• digestive disorders,

Those who love to eat heartily in excess of measure, in particular, abuse fatty foods, are predisposed to the disease. Or, on the contrary, people who thoughtlessly experiment with diets. But besides the excesses with food intake, there are other important factors that affect the development of gallstone disease:

• diabetes mellitus
• pregnancy
• sedentary
• hereditary metabolic disorders
• consequences of malaria
• viral hepatitis
• typhoid or acute intestinal infection
• alcohol abuse

Symptoms of cholelithiasis

• colic,
• nausea,
• vomiting,
• bitterness in the mouth,
• high temperature as an indication that a bacterial infection has gone to “migrate” through the body.

One of the main signs of cholelithiasis is acute colic. Why does it hurt? The feeling of sharp pain in the right hypochondrium can be caused by stagnation of bile in the biliary tract or damage to the inner wall of the bladder by stones.

According to WHO statistics, according to the age scale, pathology occurs after 70 years in almost a third of the population of the entire planet. And much more it affects not men, but women.

Where can I get help?

If you experience any of the above symptoms, you should make an appointment with a gastroenterologist. It is important to act quickly and stop the development of the disease in time. If the gastroenterologist finds that you need urgent surgery, you will need to contact the surgeon.

Odrex Medical House employs professional surgeons and gastroenterologists who help to cope with such a problem every day. They will conduct an accurate diagnosis of your body and prescribe targeted drug therapy. All examinations are painless and safe. Only in case of emergency, doctors can refer to the operation.

Diagnosis of cholelithiasis

Initially, the disease may develop quietly, the symptoms are sometimes not noticeable at all and progress in a latent form. Therefore, in order to detect them, the doctor will advise you to do an ultrasound. One of the most informative ways to determine the state of the biliary system is MRI of the abdominal organs (magnetic resonance imaging). The patient is placed in the tomograph tunnel. And with the help of radio frequency pulses, specialists receive images of the organs in question.

But in order to accurately find out the specific focus of the disease and determine the boundaries of the area affected by the disease, the doctor can send for additional examinations:

• computed tomography of the abdominal organs,
• fibrogastroscopy (with optical instruments, diagnosticians check the functioning of the mucous membrane of the esophagus, duodenum and stomach),
• colonoscopy (examination of the colon).

All examinations are carried out by experts using top-class equipment.

Methods of treatment of cholelithiasis

Based on the obtained diagnostic results, the doctor prescribes treatment: conservative or surgical.

The basis of conservative treatment is the adjustment of the nutrition system. Doctors recommend switching to fractional meals (5-6 times a day). And also reduce the consumption of animal fats in general and foods high in cholesterol. If, within 3-4 months, the proper effect of dietary compliance does not follow, then it is necessary to think about surgical treatment.

Surgical treatment. Operation is a radical measure, but it is needed in urgent cases. In cholelithiasis, the most popular method of surgical intervention is laparoscopic cholecystectomy. This is a minimally invasive method; an operation to remove the gallbladder is performed without incisions (through punctures of the abdominal wall). The expert inserts a telescope tube connected to a video camera and special manipulators into the punctures to carry out the operation.

Laparoscopy has many advantages

• fast recovery time;
• pain after the person regains consciousness is almost imperceptible;
• good cosmetic effect – scars on the body are barely noticeable.

But if the patient has cardiovascular disease, then instead of laparoscopy, the surgeon may insist on open cholecystectomy. Open cholecystectomy is the removal of the gallbladder through incisions in the upper right side of the abdomen.

How quickly the patient will return to the normal rhythm of life after the operation

After the laparoscopy procedure, the patient will be discharged from the hospital on the 2-4th day. Whereas after the traditional invasive intervention, the operated person is released on the 10-14th day.

The recovery period after laparoscopy is approximately 4-5 weeks. During this period of time, it is worth taking care of yourself and not “playing” with physical activity. And also wear soft underwear so as not to irritate the skin. In the case of traditional surgery, it is not allowed to strain the abdominal muscles for a long time – for 3 months as part of the rehabilitation phase. Then all restrictions are allowed to be removed.

Surgeon of the highest category David Makhatadze. Work experience — 25 years

Q&A

How to avoid cholelithiasis?

This is quite acceptable if you undergo an annual ultrasound screening of the abdominal organs and regularly visit a gastroenterologist. For prevention, a healthy body mass index should be maintained: body weight should correspond to its height. Norm: 18.5 – 24.99.

Avoid periods of prolonged fasting. At the same time, it is recommended to keep the daily norm of water in volumes of 1. 5-2 liters.

Can I drink alcohol during treatment and why can’t I fast?

Alcohol must be avoided, as it interferes with the functioning of the system that produces bile. And fasting is harmful because it interferes with the natural accumulation of bile. During diets, bile flows into the intestines and, without food lubrication, has a destructive effect on it. Nutrition for cholelithiasis is an important factor that directly affects recovery.

When is the best time to have surgery?

It is better to perform the operation in a state of remission (temporary weakening of the disease). Then the recovery will be much faster.

I am advised to have my gallbladder removed. How can you live without such an important organ?

Yes, this is a last resort. But sometimes you can’t do without it. If the bubble does not fulfill its functions, then it only brings harm. If the failed organ is not eliminated in time, then irreversible consequences may occur: purulent cholecystitis (the inflammatory process takes on a purulent character, and this, in turn, can lead to death), complete blockage of the biliary tract with stones, jaundice.

After removal of the gallbladder, the liver will continue to produce bile. But then, through the bile ducts, it will begin to flow directly into the duodenum. The body will adapt to the new conditions, but it will take time for this. In just a few months, he will be able to smoothly regulate the release of bile again

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Cholelithiasis (GSD) is the formation of stones in the biliary system. If the stones are localized in the gallbladder, the pathology is called “cholecystolithiasis”, in the common bile duct – “choledocholithiasis”, in the intrahepatic ducts – “intrahepatic cholelithiasis”. Gallstone disease in Russia and Europe occurs in 10-15% of the population, and among people over 60 years of age – in 30%. In Asia, the disease is diagnosed 3-5 times less often, due to the peculiarities of nutrition.

Why gallstones occur

Stones in the bile ducts are formed when the chemical composition of bile changes, the accumulation of a large amount of bile acids, cholesterol, bilirubin in it. This condition is called “lithogenic bile” and is the first stage of the disease. Then small bubbles form from cholesterol and pigments, gradually merging into soft crystals. Over time, the crystals become hard and coalesce to form a gallstone.

Risk factors

● In the elderly, cholelithiasis occurs 2 times more often than in young and middle-aged people
● in women of reproductive age, the risk is 2-3 times higher than in men
● in pregnant women with repeated pregnancies, the risk of gallstones increases 10-11 times
● Menopausal women who receive hormone therapy have a 3. 7 times greater risk of gallstone disease
● in patients with diabetes mellitus, obesity, cirrhosis of the liver, the likelihood of cholelithiasis increases by 3-10 times

Signs of gallstone disease

Outside of an attack of biliary colic, the symptoms of the disease are nonspecific. Patients complain of pain and heaviness in the right hypochondrium, which are aggravated after eating fatty foods and alcohol. Associated symptoms: bitterness in the mouth, nausea, abdominal discomfort, flatulence. Digestive disorders often occur, unstable stools are observed. If the patient goes to the doctor at this stage, then it is possible to carry out successful conservative or minimally invasive treatment and avoid complications.

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Biliary (hepatic) colic

Intense pain in the right hypochondrium occurs when the bile duct is blocked by a stone and bile secretion is completely stopped. As a result, the gallbladder is overstretched, which causes typical visceral pain. Painful sensations can be given under the right shoulder blade, in the right shoulder and neck. Colic is accompanied by fever, nausea and vomiting, fluctuations in pulse and blood pressure.

Which doctor to contact

If you are concerned about discomfort in the right hypochondrium and other dyspeptic symptoms, it is recommended to contact an ID-Clinic physician. The doctor conducts an initial diagnosis, collects complaints and an anamnesis of the disease, and makes palpation of the abdomen. If a specialist suspects cholelithiasis, he directs the patient to an ultrasound of the liver and gallbladder, prescribes blood, urine and feces tests. If necessary, a consultation with a hepatologist is carried out.

Treatment of cholelithiasis

Lifestyle correction
Patients are advised to eat 5-6 times a day, enrich the diet with fiber, protein foods with a minimum fat content. Fried, fatty, smoked dishes are excluded. Regular physical activity helps control body weight.

Medical treatment
In a limited number of patients, stone-dissolving drugs can be used to avoid surgery. With biliary colic, a complex of drugs is prescribed: analgesics, antispasmodics, prokinetics.

Surgical treatment
Removal of stones in an operative way is the main method of treatment of cholelithiasis. Given the size and type of stones, minimally invasive interventions can be used: contact chemical litholysis, percutaneous shock wave lithotripsy, and classical operations: cholecystectomy, percutaneous cholecystolithotomy, cholecystostomy.

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А04. 14.001.003	Ultrasound of the hepatobiliary zone (liver, gallbladder, pancreas)	2400 ₽
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А04.14.002.002	Dynamic echo-cholecystography (determination of the function of the gallbladder and sphincter of Oddi)	2000 ₽
А04.14.001.004	Ultrasound of the biliary tract (choledoch, intrahepatic bile ducts)	1500 ₽
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