Location of gallstones: Gallstones – Symptoms and causes
Gallstones Quiz: Causes, Symptoms, Treatment
Images provided by:
UpToDate.com. Patient education: Gallstones (The Basics).
The National Institute of Diabetes and Digestive and Kidney Diseases. Symptoms & Causes of Gallstones.
Unity Point Health. Pinpointing the Pain: Gallstones & The Places They Get Stuck (Infographic).
NHS. Complications Gallstones.
UpToDate.com. Gallstones: Epidemiology, risk factors and prevention.
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Gallstones & Bile Duct Stones | MUSC Health
What are gallstones?
Gallstones, which are created in the gallbladder, form when substances in the bile create hard, crystal-like particles. Cholesterol stones, as the name implies, are made of cholesterol and appear light in color. Eighty percent of gallstones are formed this way.
Pigment stones are small, dark stones made of bilirubin and calcium salts that are found in bile. About twenty percent of gallstones are pigment stones. Risk factors for pigment stones include:
- cirrhosis of the liver
- biliary tract infections
- hereditary blood cell disorders (such as sickle cell anemia)
Gallstones can be as small as a grain of salt or as large as a golf ball. The gallbladder may develop many smaller stones, or a single, often large one. It may even develop several thousand stones.
What are bile duct stones?
Gallstones that move out of the gallbladder can pass into your stomach. However, a stone may become lodged in your bile duct due to the size of the stone or the anatomy of the biliary tree. Thus, bile duct stones are gallbladder stones that have become lodged in the bile duct. Stones that become stuck in the ducts that lead to the duodenum can be both agonizing and dangerous.
What causes gallstones?
Advancements have been made in better understanding the gallstone formation process. Gallstones may be caused by:
- inherited body chemistry
- body weight
- gallbladder movement (the gallbladder is a muscular sack that contracts)
- diet and lifestyle
When the bile contains too much cholesterol and not enough bile salts, cholesterol gallstones may develop. Aside from a high concentration of cholesterol, there are two other factors that seem to be of importance in causing gallstones.
Movement of the gallbladder is referred to as gallbladder motility. This small but muscular organ squeezes to force bile into the bile duct. If the gallbladder does not perform as it should, the bile may not be able to makes its way into the bile duct, instead becoming concentrated and forming small crystals.
Gallstones may also be created by proteins in the liver and bile. These proteins may either promote cholesterol crystallization into gallstones.
Other factors also seem to play a role in causing gallstones but how is not clear.
- Low calorie, and rapid weight-loss diets
- Prolonged fasting
- Increased levels estrogen as a result of pregnancy
- Hormone therapy
- Birth control pills
No clear relationship has been proven between gallstone formation and a particular diet.
Who is at risk for gallstones?
Gallstones affect approximately one million people every year, with women being twice as likely to become afflicted than men. They will join the estimated 20 million Americans —roughly 10 percent of the population— who already have gallstones.
Those who are most likely to develop gallstones are:
- Women, ages 20 – 60
- Men and women, ages 60+
- Men and women who are overweight
- Men and women who go on “crash” diets or who lose of lot of weight quickly
- Pregnant women, or women who have used birth control pills or estrogen replacement therapy
- Native Americans
What are the symptoms of gallstones?
A person with gallstones may have what are called “silent stones”. Studies show that most people with silent stones may not experience any symptoms at all for awhile, remaining symptom-free for years and requiring no treatment. Silent stones may go undiagnosed until they begin to cause discomfort.
For those that are not quite so lucky, the symptoms my include
- Acute pain, possibly very severe, that occurs very suddenly. It may last a few minutes, or many hours
- Pain is usually located behind your breastbone, but may occur in the upper right abdominal area
- Pain between your shoulder-blades
- Chills and fever
- Nausea and vomiting
It is not uncommon for attacks to be separated by weeks, months, or even years.
What problems can occur?
A common complication cause by gallstones is blockage of the cystic duct. Sometimes gallstones may make their way out of the gallbladder and into the cystic duct, the channel through which bile travels from the gallbladder to the small intestine. An inflammation of the gallbladder (cholecystitis) can occur if the flow of bile in the cystic duct is severely impeded or blocked by any gallstones.
A less common but more serious problem occurs if the gallstones become lodged in the bile ducts between the liver and the small intestine. This condition, called cholangitis, can block bile flow from the gallbladder and liver, causing pain, jaundice and fever.
Gallstones may also interfere with the flow of digestive fluids into the small intestine, leading to an inflammation of the pancreas, or pancreatitis. Prolonged blockage of any of these ducts can cause severe damage to the gallbladder, liver, or pancreas, which can be fatal.
How are gallstones diagnosed?
Diagnostic methods for detecting gallstones may include:
- barium exam
- CT scan
When actually looking for gallstones, the most common diagnostic tool is ultrasound. An ultrasound examination, also known as ultrasonography, uses sound waves to create images of the various abdominal organs … including the gallbladder. If stones are present, the sound waves will bounce off the stones, revealing their location.
Ultrasound has several advantages.
- It is a noninvasive technique – nothing is injected into or penetrates the body
- It is painless – there are no known side effects
- It does not involve radiation
Occassionaly, other tests needed to detect small stones, or verify their non-existance, may be required.
- MRI/MRCP — a painless, magnetic imaging technique
- endoscopic ultrasound — a minimally invasive procedure that can visualize tissue
- ERCP — for diagnosis and management of stones in the bile duct
Other gallbladder diseases
Pain and inflammation of the gallbladder can occur in the absence of gallstones.
Acalculus cholecystitis, or inflammation of the gallbladder without stones, may occur in conjunction with other severe illnesses. This condition occurs when the gallbladder fluids become infected as a result of being stagnant during a long illness.
Biliary dyskinesia, or disordered function of the gallbladder, describes a condition in which the gallbladder cannot empty properly due to inflammation or spasm of its drainage system (the cystic duct). When you eat a meal, the gallbladder is prompted to contract, and in doing so, bile is forced into the duodenum. If the gallbladder cannot contract, the pressure exerted on the gallbladder causes pain.
A scanning technique, known as an HIDA scan, uses radioactive isotopes to help diagnose both of these conditions. This shows whether the gallbladder is blocked, or cannot drain completely. These conditions are treated in the same way as gallbladder stones.
Cancer, which can develop in the gallbladder wall, appears to be more common in patients with gallstones. Unfortunately, it often does not cause symptoms until the cancer has spread to the liver or adjacent bile duct. If technically possible, surgical removal is the recommended course of action.
Each year more than 500,000 Americans have gallbladder surgery. This surgery, called cholecystectomy, is the most common method for treating gallstones despite the development of some nonsurgical techniques. There are two types of cholecystectomy: the standard “open” cholecystectomy; and, a less invasive procedure called laparoscopic cholecystectomy.
The standard cholecystectomy is a major abdominal surgery in which the surgeon removes the gallbladder through a 5-to-8 inch incision. The person will remain in the hospital for about a week, and convalesce at home for several weeks after.
Laparoscopic cholecystectomy is a more minimally invasive method of gallbladder removal that accounts for approximately 95% of all cholecystectomies performed. Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the insertion of surgical instruments and a small video camera. The surgeon is provided with a close-up view from inside the body sent by the camera to a video monitor. He is then able to perform the procedure by manipulating his surgical instruments all while watching the monitor.
Laparoscopic cholecystectomy does not require the abdominal muscles to be cut, and thus results in less pain, quicker healing, improved cosmetic results, and fewer complications such as infection. Recovery usually requires only a night in the hospital, and several days recuperation at home.
Several methods are available, but are used only in special circumstances.
Patients with acute inflammation of the gallbladder (and acalculus cholecystitis) may sometimes be treated first with “percutaneous drainage”. This involves inserting a tube and needle (also known as a catheter) straight into the gallbladder to siphon the harmful fluids. Cholecystectomy is performed after the acute situation has settled.
Special medicines can dissolve gallstones which are composed of cholesterol. However, this method works only when there is no blockage, and is usually more practical with smaller stones. However, treatment usually requires many months or years (and stones may return when the treatment is stopped). Thus, it is used only rarely in certain individuals who cannot tolerate surgery.
Extracorporeal shockwave lithotripsy (ESWL) is an excellent method for treating stones in the kidneys. However, ESWL often requires several treatments, and has other drawbacks, including the possibility of stone recurrence. As a result, this treatment method is rarely used.
ESWL can also be used to break up stones in the gallbladder. Resulting stone fragments usually then pass through into the small bowel.
Treatment of bile duct stones
A bile duct stone as seen on ERCP.
Approximately 10% of patients with stones in the gallbladder also have stones in the bile duct. These can cause acute blockage to the bile duct with cholangitis, or acute pancreatitis. When blockage can cause life threatening illness, emergency treatment is best applied with ERCP. The gastroenterologistpasses an endoscope down to the bile duct opening, and then releases the stone into the duodenum with a small cutting incision (sphincterotomy).
Gallstones top to toe: what the radiologist needs to know | Insights into Imaging
The broad spectrum of gallstone-related disease can be broken down based on the anatomical locations in which they occur (Fig. 8).
Illustration outlines the multitude of locations within the digestive tract where gallstones can manifest and lists the pathological processes that occur in these locations
Unsurprisingly, the most common location for gallstones and thus gallstone-related disease is the gallbladder.
Biliary colic is caused when a stone temporarily obstructs the drainage from the cystic duct, resulting in severe cramping abdominal and right upper quadrant pain that can radiate to the back and right shoulder tip as the gallbladder contracts (typically, these symptoms are temporary and subside with resolution of the cystic duct obstruction). Ultrasonography will often demonstrate cholelithiasis without associated complications in patients with simple biliary colic.
Calculous cholecystitis refers to infection and inflammation of the gallbladder wall caused by irritation from gallstones, and this can be an acute or chronic process. The typical clinical presentation of acute cholecystitis is of right upper quadrant pain, with or without radiation to the right shoulder, which is more constant compared to the intermittent pain seen in biliary colic. There is usually associated pyrexia and other infective symptoms such as nausea and vomiting. The typical imaging features of acute cholecystitis are as follows: gallbladder wall thickening, pericholecystic fluid and a distended gallbladder  (Figs. 9 and 10). Chronic cholecystitis is caused by repeated episodes of biliary colic and acute cholecystitis over time, and in contrast to acute cholecystitis, the gallbladder is usually shrunken down and the wall is thickened and scarred.
Sagittal ultrasound image of the gallbladder which contains hyperechoic gallstones. There is gallbladder wall thickening (black arrow) and pericholecystic fluid (white arrow) consistent with acute calculous cholecystitis
Coronal (a) and axial (b) contrast-enhanced CT of the abdomen. There is gallbladder wall thickening (black arrow) and pericholecystic fluid (white arrows) consistent with acute cholecystitis
Emphysematous cholecystitis (EC) is a particular entity in which the gallbladder wall becomes necrotic, and this typically occurs with bacterial organisms such as the gas forming organisms such as clostridium, or with E. coli infections. Although rare, EC is associated with high mortality secondary to gallbladder perforation and gangrene, and EC is seen more commonly in patients with diabetes mellitus, coronary artery disease and SIRS (systemic inflammatory response syndrome) . On plain films and CT, gas can be seen within the gallbladder wall (Fig. 11).
Coronal contrast-enhanced CT of the abdomen demonstrating a markedly distended gallbladder. There are multiple locules of gas within the anti-dependent gallbladder wall (arrow). Findings are consistent with emphysematous cholecystitis
If an episode of acute cholecystitis is particularly severe or left untreated, it can progress to a gallbladder perforation. This can be appreciated on US or on CT and MRI with pericholecystic abscesses or a defect in the gallbladder wall and a rim of bilious fluid outside of the gallbladder (Fig. 12). There may be an associated intrahepatic abscess which may require radiological or surgical drainage. Other rare complications of severe cholecystitis include cholecysto-cutaneous fistula and thrombophlebitis of a recanalised umbilical vein (Figs. 13 and 14).
Axial contrast-enhanced CT of the abdomen. There is gallbladder wall thickening and pericholecystic fluid consistent with acute cholecystitis. There is a defect in the medial gallbladder wall with a hypoattenuating collection within segment 5 of the liver (arrow). Appearances are consistent with gallbladder perforation and hepatic abscess
Axial (a) and coronal (b) contrast-enhanced CT of the abdomen. There is extensive gallbladder wall thickening and stranding with the inflammatory process extending through the peritoneum to the right anterolateral abdominal wall with fistulation to the skin (arrows)
Axial (a), coronal (b) and sagittal (c) contrast-enhanced CT of the abdomen. There is gallbladder wall thickening and pericholecystic fluid consistent with acute cholecystitis. There is marked expansion and oedema surrounding the falciform ligament (arrows). Appearances are due to thrombophlebitis of a recanalised umbilical vein
Along the spectrum of chronic cholecystitis is the porcelain gallbladder, where calcification of the gallbladder wall is caused by repeated episodes of cholecystitis (Fig. 15). There is evidence of a causal relationship between gallstones, chronic cholecystitis and gallbladder carcinoma (Fig. 16), and malignancy often presents at an advancedstage; however, definitive proof is lacking .
Axial (a) and sagittal (b) contrast-enhanced CT of the abdomen demonstrating peripheral calcification of the gallbladder wall (arrows) consistent with porcelain gallbladder
Sagittal ultrasound of the gallbladder demonstrating a soft tissue mass within the gallbladder with internal vascularity consistent with a gallbladder carcinoma
A gallbladder mucocoele results when a stone obstructs the cystic duct causing the gallbladder to become distended with bile. When the bile within the mucocoele becomes infected, this is known as a gallbladder empyema (Fig. 17).
a Sagittal ultrasound of a distended gallbladder with an impacted stone in the gallbladder neck. Mild associated gallbladder wall thickening. b Axial contrast-enhanced CT of the abdomen in the same patient, again demonstrating a distended gallbladder with an impacted hyperattenuating stone in the gallbladder neck. There is subtle associated fat stranding. Findings are consistent with a gallbladder mucocoele. The gallbladder wall thickening and fat stranding are suggestive of possible empyema
Mirizzi syndrome refers to a gallstone that is impacted in the cystic duct or neck of gallbladder which causes extrinsic compression on the common bile duct resulting in obstructive jaundice (Fig. 18).
a Maximum intensity projection (MIP). b Axial T2-weighted MRCP image of the biliary tree. The gallbladder is distended with extensive intrahepatic biliary duct dilatation. The common bile duct is normal in calibre. Appearances are consistent with Mirizzi syndrome, with a stone in Hartmann’s pouch of the gallbladder causing extrinsic compression of the common hepatic duct
Both biliary dilatation and the offending gallstone can be seen on ultrasound; however, cross-sectional imaging with MRI or CT, or ERCP, may be needed to confirm that biliary dilatation is secondary to compression from a gallbladder/cystic duct stone rather than secondary to a CBD calculus.
The next anatomical location where gallstones can be found is outside the gallbladder but within the pancreaticobiliary system. When gallstones exit the gallbladder into the common bile duct (choledocholithiasis), they can often obstruct the normal drainage of bile which can lead to jaundice. This is typically associated with pain, unlike malignant biliary obstruction which is characteristically painless (Fig. 19).
(a) Sagittal ultrasound, (b) fluoroscopic ERCP cholangiogram, (c) T2-weighted axial MRI and (d) coronal MIP MRI of the biliary tree. These images demonstrate multiple filling defects (arrows) within the common bile duct with associated biliary duct dilatation consistent with obstructing choledocholithiasis
The obstruction of biliary drainage and stasis of bile may result in infection in the form of ascending cholangitis and associated sepsis. The clinical picture associated with this is described in Reynolds’ pentad consisting of fever, right upper quadrant pain, jaundice, hypotension and altered mental status. These patients may require urgent decompression of the biliary system.
In rare cases, there can be retrograde passage of gallstones into the common hepatic duct or the right or left main hepatic ducts, or stones can form in intrahepatic ducts due to biliary stasis.
If a gallstone passes down the common bile duct and comes to rest at the ampulla of Vater, it may block the drainage of the pancreatic duct causing back pressure on the pancreatic cells and resulting in gallstone pancreatitis. These patients present with epigastric pain radiating to the back and the severity ranges from mild to severe. There is a significant mortality associated with severe pancreatitis, and critically ill patients should be managed in a high dependency or intensive care monitored environment. While imaging is not usually required or indicated to confirm the diagnosis of acute pancreatitis, an ultrasound of the gallbladder can confirm or rule out the presence of gallstones. CT abdomen/pelvis is best performed 48 h after the onset of symptoms to assess for complications of pancreatitis such as peripancreatic collections or pancreatic necrosis (Fig. 20).
Axial contrast-enhanced CT of the abdomen (a) and axial fat-suppressed T2-weighted MRI of the abdomen (b) in the same patient demonstrating extensive inflammation and oedema of the pancreas secondary to gallstone pancreatitis with a peripancreatic collection (arrow)
In general, larger gallstones are more likely to obstruct higher in the common bile duct, and as such are more likely to cause obstructive jaundice or cholangitis. Smaller gallstones are more likely to cause pancreatitis as they more freely pass down to the level of the ampulla of Vater [4, 5].
Gallstones can also cause pathology outside of the biliary system. The most common cause, although rare, is a cholecystoenteric fistula. Chronic irritation from a large gallstone can erode through the gallbladder wall with fistulisation into small bowel. This can be seen on imaging with air seen within the gallbladder or biliary tree (pneumobilia).
When a gallstone passes through the fistula into the small bowel, this can result in intestinal obstruction, either proximal or more commonly distal. The most common place for distal small bowel obstruction and gallstone ileum is at the level of ileocecal valve as this is the narrowest point; however, gallstone ileus can occur anywhere in the gastrointestinal tract. The diagnosis is suggested on abdominal X-ray by the presence of pneumobilia in the right upper quadrant with dilated loops of bowel consistent with bowel obstruction. Gallstone ileus is more accurately diagnosed with CT which may show pneumobilia or may directly demonstrate the presence of a cholecystoenteric fistula and associated bowel obstruction (Fig. 21).
Coronal (a) and axial (b) contrast-enhanced CT of the abdomen demonstrating multiple dilated loops of small bowel. There is a 3-cm peripherally hyperattenuating obstructing gallstone in the left flank (arrow 1). There is an extensive inflammatory process in the gallbladder bed with air in the gallbladder (arrow 2) consistent with a cholecystoenteric fistula. Appearances are consistent with a bowel obstruction secondary to a gallstone ileus
Bouveret’s syndrome is a particular eponymous syndrome in which a stone obstructs the upper GI tract proximally at the level of duodenum or gastric outlet. Patients typically present with copious vomiting owing to the proximal level of obstruction. There may be little or no small bowel dilatation; in particular, the X-ray abdomen may be completely normal which can falsely reassure. Imaging will demonstrate evidence of gastric outlet or duodenal obstruction related to a gallstone in the upper GI tract (Fig. 22).
Ultrasound (a), CT (b, c), MRI (d) and endoscopic images (e). Demonstrating a large calcified gallstone in the proximal duodenum with a massively dilated stomach. Findings are consistent with a proximal bowel obstruction consistent with Bouveret’s syndrome
Finally, there are a number of imaging features post-cholecystectomy that the radiologist should be aware of. Immediate complications can include post-operative bleeding or an injury to the common bile duct resulting in a bile leak and subsequent biloma. CT is the optimal imaging modality for the initial imaging of post-operative complications, where these complications and fluid collections are well appreciated. It can be difficult to differentiate between blood and bile on CT, and measuring a region of interest to obtain the Hounsfield attenuation value of the fluid can help differentiate between the two. The typical Hounsfield unit of blood is 25–75 and that of bile is usually < 20; however, there can be some overlap. Other factors should be considered to ascertain the aetiology of any visualised collection, for example, a layering haemotocritl level with altered attenuation values can be a feature seen with haemorrhagic collections where the inferior denser (haemorrhagic) component is seen dependently  (Fig. 23).
Axial and coronal contrast enhanced CT of the abdomen in a patient several hours post-cholecystectomy. There is large volume perihepatic fluid with an average Hounsfield unit of 55 consistent with post-cholecystectomy bleeding
Dropped gallstones at time of laparoscopy can have a delayed presentation with post-operative complications such as intrabdominal abscess formation and CT demonstrating a radio-opaque gallstone surrounded by abscess (Fig. 24). Gallstone abscesses without radiopaque gallstones can pose a particular diagnostic challenge as the nidus for infection is not definitely confirmed on imaging. Abscesses related to dropped gallstones can be complex and may extend through abdominal planes and extend extra-peritoneally into adjacent subcutaneous and soft tissue plains. The clinical history will often include a history of prior or difficult cholecystectomy. Gallbladder clips or an absent gallbladder can be seen on cross-sectional imaging as clues.
Axial and sagittal images of a contrast-enhanced CT abdomen in a patient several days post-laparoscopic cholecystectomy. There is a rim-enhancing fluid collection compatible with an abscess which contains multiple (dropped) gallstones
Patients with occult choledocholithiasis that proceed to cholecystectomy can present with obstructive jaundice and cholangitis in the post-operative period. It is important that any patient in whom choledocholithiasis is suspected undergo MRCP prior to surgery. Alternatively, an intra-operative cholangiogram or choledochoscope can be performed intra-operatively to ensure the common bile duct is clear of stones. Late post-cholecystectomy complications can include stump cholecystitis or a retained cystic duct stump or common bile duct stone. These findings result from incomplete cholecystectomy and can be identified on imaging  (Fig. 25).
Coronal magnetic resonance MIP image of the biliary tree. The gallbladder is absent consistent with a prior cholecystectomy. There is a filling defect in the distal common bile duct (arrow) with associated biliary duct dilatation consistent with an obstructing gallstone
General Surgery – Gallstones
What are gallstones?
Gallstones are hard particles that develop in the gallbladder. The gallbladder is a small, pear-shaped organ located in the upper right abdomen—the area between the chest and hips—below the liver.
Gallstones can range in size from a grain of sand to a golf ball. The gallbladder can develop a single large gallstone, hundreds of tiny stones, or both small and large stones. Gallstones can cause sudden pain in the upper right abdomen. This pain, called a gallbladder attack or biliary colic, occurs when gallstones block the ducts of the biliary tract.
By BruceBlaus (Own work) [CC BY-SA 4.0 (http://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia Commons
What is the biliary tract?
The biliary tract consists of the gallbladder and the bile ducts. The bile ducts carry bile and other digestive enzymes from the liver and pancreas to the duodenum—the first part of the small intestine.
The liver produces bile—a fluid that carries toxins and waste products out of the body and helps the body digest fats and the fat-soluble vitamins A, D, E, and K. Bile mostly consists of cholesterol, bile salts, and bilirubin. Bilirubin, a reddish-yellow substance, forms when hemoglobin from red blood cells breaks down. Most bilirubin is excreted through bile.
The bile ducts of the biliary tract include the hepatic ducts, the common bile duct, the pancreatic duct, and the cystic duct. The gallbladder stores bile. Eating signals the gallbladder to contract and empty bile through the cystic duct and common bile duct into the duodenum to mix with food.
What causes gallstones?
Imbalances in the substances that make up bile cause gallstones. Gallstones may form if bile contains too much cholesterol, too much bilirubin, or not enough bile salts. Scientists do not fully understand why these imbalances occur. Gallstones also may form if the gallbladder does not empty completely or often enough.
The two types of gallstones are cholesterol and pigment stones:
- Cholesterol stones, usually yellow-green in color, consist primarily of hardened cholesterol. In the United States, more than 80 percent of gallstones are cholesterol stones.1
- Pigment stones, dark in color, are made of bilirubin.
Who is at risk for gallstones?
Certain people have a higher risk of developing gallstones than others:2
- Women are more likely to develop gallstones than men. Extra estrogen can increase cholesterol levels in bile and decrease gallbladder contractions, which may cause gallstones to form. Women may have extra estrogen due to pregnancy, hormone replacement therapy, or birth control pills.
- People over age 40 are more likely to develop gallstones than younger people.
- People with a family history of gallstones have a higher risk.
- American Indians have genetic factors that increase the amount of cholesterol in their bile. In fact, American Indians have the highest rate of gallstones in the United States—almost 65 percent of women and 30 percent of men have gallstones.
- Mexican Americans are at higher risk of developing gallstones.
Other factors that affect a person’s risk of gallstones include2
- Obesity. People who are obese, especially women, have increased risk of developing gallstones. Obesity increases the amount of cholesterol in bile, which can cause stone formation.
- Rapid weight loss. As the body breaks down fat during prolonged fasting and rapid weight loss, the liver secretes extra cholesterol into bile. Rapid weight loss can also prevent the gallbladder from emptying properly. Low-calorie diets and bariatric surgery—surgery that limits the amount of food a person can eat or digest—lead to rapid weight loss and increased risk of gallstones.
- Diet. Research suggests diets high in calories and refined carbohydrates and low in fiber increase the risk of gallstones. Refined carbohydrates are grains processed to remove bran and germ, which contain nutrients and fiber. Examples of refined carbohydrates include white bread and white rice.
- Certain intestinal diseases. Diseases that affect normal absorption of nutrients, such as Crohn’s disease, are associated with gallstones.
- Metabolic syndrome, diabetes, and insulin resistance. These conditions increase the risk of gallstones. Metabolic syndrome also increases the risk of gallstone complications. Metabolic syndrome is a group of traits and medical conditions linked to being overweight or obese that puts people at risk for heart disease and type 2 diabetes.
More information about these conditions is provided in the NIDDK health topic, Insulin Resistance and Prediabetes.
Pigment stones tend to develop in people who have
- cirrhosis—a condition in which the liver slowly deteriorates and malfunctions due to chronic, or long lasting, injury
- infections in the bile ducts
- severe hemolytic anemias—conditions in which red blood cells are continuously broken down, such as sickle cell anemia
What are the symptoms and complications of gallstones?
Many people with gallstones do not have symptoms. Gallstones that do not cause symptoms are called asymptomatic, or silent, gallstones. Silent gallstones do not interfere with the function of the gallbladder, liver, or pancreas.
If gallstones block the bile ducts, pressure increases in the gallbladder, causing a gallbladder attack. The pain usually lasts from 1 to several hours.1 Gallbladder attacks often follow heavy meals, and they usually occur in the evening or during the night.
Gallbladder attacks usually stop when gallstones move and no longer block the bile ducts. However, if any of the bile ducts remain blocked for more than a few hours, complications can occur. Complications include inflammation, or swelling, of the gallbladder and severe damage or infection of the gallbladder, bile ducts, or liver.
A gallstone that becomes lodged in the common bile duct near the duodenum and blocks the pancreatic duct can cause gallstone pancreatitis—inflammation of the pancreas.
Left untreated, blockages of the bile ducts or pancreatic duct can be fatal.
When should a person talk with a health care provider about gallstones?
People who think they have had a gallbladder attack should notify their health care provider. Although these attacks usually resolve as gallstones move, complications can develop if the bile ducts remain blocked.
People with any of the following symptoms during or after a gallbladder attack should see a health care provider immediately:
- abdominal pain lasting more than 5 hours
- nausea and vomiting
- fever—even a low-grade fever—or chills
- yellowish color of the skin or whites of the eyes, called jaundice
- tea-colored urine and light-colored stools
These symptoms may be signs of serious infection or inflammation of the gallbladder, liver, or pancreas.
How are gallstones diagnosed?
A health care provider will usually order an ultrasound exam to diagnose gallstones. Other imaging tests may also be used.
- Ultrasound exam. Ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure. A specially trained technician performs the procedure in a health care provider’s office, outpatient center, or hospital, and a radiologist—a doctor who specializes in medical imaging—interprets the images. Anesthesia is not needed. If gallstones are present, they will be visible in the image. Ultrasound is the most accurate method to detect gallstones.
- Computerized tomography (CT) scan. A CT scan is an x ray that produces pictures of the body. A CT scan may include the injection of a special dye, called contrast medium. CT scans use a combination of x rays and computer technology to create three-dimensional (3-D) images. CT scans require the person to lie on a table that slides into a tunnel-shaped device where the x rays are taken. An x-ray technician performs the procedure in an outpatient center or hospital, and a radiologist interprets the images. Anesthesia is not needed. CT scans can show gallstones or complications, such as infection and blockage of the gallbladder or bile ducts. However, CT scans can miss gallstones that are present.
- Magnetic resonance imaging (MRI). MRI machines use radio waves and magnets to produce detailed pictures of the body’s internal organs and soft tissues without using x rays. A specially trained technician performs the procedure in an outpatient center or hospital, and a radiologist interprets the images. Anesthesia is not needed, though people with a fear of confined spaces may receive light sedation. An MRI may include the injection of contrast medium. With most MRI machines, the person lies on a table that slides into a tunnel-shaped device that may be open ended or closed at one end; some newer machines allow the person to lie in a more open space. MRIs can show gallstones in the ducts of the biliary system.
- Cholescintigraphy. Cholescintigraphy—also called a hydroxyl iminodiacetic acid scan, HIDA scan, or hepatobiliary scan—uses an unharmful radioactive material to produce pictures of the biliary system. In cholescintigraphy, the person lies on an exam table and a health care provider injects a small amount of unharmful radioactive material into a vein in the person’s arm. The health care provider may also inject a substance that causes the gallbladder to contract. A special camera takes pictures of the radioactive material as it moves through the biliary system. A specially trained technician performs the procedure in an outpatient center or hospital, and a radiologist interprets the images. Anesthesia is not needed. Cholescintigraphy is used to diagnose abnormal contractions of the gallbladder or obstruction of the bile ducts.
- Endoscopic retrograde cholangiopancreatography (ERCP). ERCP uses an x ray to look into the bile and pancreatic ducts. After lightly sedating the person, the health care provider inserts an endoscope—a small, flexible tube with a light and a camera on the end—through the mouth into the duodenum and bile ducts. The endoscope is connected to a computer and video monitor. The health care provider injects contrast medium through the tube into the bile ducts, which makes the ducts show up on the monitor. The health care provider performs the procedure in an outpatient center or hospital. ERCP helps the health care provider locate the affected bile duct and the gallstone. The stone is captured in a tiny basket attached to the endoscope and removed. This test is more invasive than other tests and is used selectively.
Health care providers also use blood tests to look for signs of infection or inflammation of the bile ducts, gallbladder, pancreas, or liver. A blood test involves drawing blood at a health care provider’s office or commercial facility and sending the sample to a lab for analysis.
Gallstone symptoms may be similar to those of other conditions, such as appendicitis, ulcers, pancreatitis, and gastroesophageal reflux disease.
Sometimes, silent gallstones are found when a person does not have any symptoms. For example, a health care provider may notice gallstones when performing ultrasound for a different reason.
How are gallstones treated?
If gallstones are not causing symptoms, treatment is usually not needed. However, if a person has a gallbladder attack or other symptoms, a health care provider will usually recommend treatment. A person may be referred to a gastroenterologist—a doctor who specializes in digestive diseases—for treatment. If a person has had one gallbladder attack, more episodes will likely follow.
The usual treatment for gallstones is surgery to remove the gallbladder. If a person cannot undergo surgery, nonsurgical treatments may be used to dissolve cholesterol gallstones. A health care provider may use ERCP to remove stones in people who cannot undergo surgery or to remove stones from the common bile duct in people who are about to have gallbladder removal surgery.
Surgery to remove the gallbladder, called cholecystectomy, is one of the most common operations performed on adults in the United States.
The gallbladder is not an essential organ, which means a person can live normally without a gallbladder. Once the gallbladder is removed, bile flows out of the liver through the hepatic and common bile ducts and directly into the duodenum, instead of being stored in the gallbladder.
Surgeons perform two types of cholecystectomy:
Laparoscopic cholecystectomy. In a laparoscopic cholecystectomy, the surgeon makes several tiny incisions in the abdomen and inserts a laparoscope—a thin tube with a tiny video camera attached. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of organs and tissues. While watching the monitor, the surgeon uses instruments to carefully separate the gallbladder from the liver, bile ducts, and other structures. Then the surgeon removes the gallbladder through one of the small incisions. Patients usually receive general anesthesia.
Most cholecystectomies are performed with laparoscopy. Many laparoscopic cholecystectomies are performed on an outpatient basis, meaning the person is able to go home the same day. Normal physical activity can usually be resumed in about a week.3
Open cholecystectomy. An open cholecystectomy is performed when the gallbladder is severely inflamed, infected, or scarred from other operations. In most of these cases, open cholecystectomy is planned from the start. However, a surgeon may perform an open cholecystectomy when problems occur during a laparoscopic cholecystectomy. In these cases, the surgeon must switch to open cholecystectomy as a safety measure for the patient.
To perform an open cholecystectomy, the surgeon creates an incision about 4 to 6 inches long in the abdomen to remove the gallbladder. 4 Patients usually receive general anesthesia. Recovery from open cholecystectomy may require some people to stay in the hospital for up to a week. Normal physical activity can usually be resumed after about a month.3
A small number of people have softer and more frequent stools after gallbladder removal because bile flows into the duodenum more often. Changes in bowel habits are usually temporary; however, they should be discussed with a health care provider.
Though complications from gallbladder surgery are rare, the most common complication is injury to the bile ducts. An injured common bile duct can leak bile and cause a painful and possibly dangerous infection. One or more additional operations may be needed to repair the bile ducts. Bile duct injuries occur in less than 1 percent of cholecystectomies.5
Nonsurgical Treatments for Cholesterol Gallstones
Nonsurgical treatments are used only in special situations, such as when a person with cholesterol stones has a serious medical condition that prevents surgery. Gallstones often recur within 5 years after nonsurgical treatment.6
Two types of nonsurgical treatments can be used to dissolve cholesterol gallstones:
- Oral dissolution therapy. Ursodiol (Actigall) and chenodiol (Chenix) are medications that contain bile acids that can dissolve gallstones. These medications are most effective in dissolving small cholesterol stones. Months or years of treatment may be needed to dissolve all stones.
- Shock wave lithotripsy. A machine called a lithotripter is used to crush the gallstone. The lithotripter generates shock waves that pass through the person’s body to break the gallstone into smaller pieces. This procedure is used only rarely and may be used along with ursodiol.
Eating, Diet, and Nutrition
Factors related to eating, diet, and nutrition that increase the risk of gallstones include
- rapid weight loss
- diets high in calories and refined carbohydrates and low in fiber
People can decrease their risk of gallstones by maintaining a healthy weight through proper diet and nutrition.
Ursodiol can help prevent gallstones in people who rapidly lose weight through low-calorie diets or bariatric surgery. People should talk with their health care provider or dietitian about what diet is right for them.
Points to Remember
- Gallstones are hard particles that develop in the gallbladder.
- Imbalances in the substances that make up bile cause gallstones. Gallstones may form if bile contains too much cholesterol, too much bilirubin, or not enough bile salts. Scientists do not fully understand why these imbalances occur.
- Women, people over age 40, people with a family history of gallstones, American Indians, and Mexican Americans have a higher risk of developing gallstones.
- Many people with gallstones do not have symptoms. Gallstones that do not cause symptoms are called asymptomatic, or silent, gallstones.
- If gallstones block the bile ducts, pressure increases in the gallbladder, causing a gallbladder attack.
- Gallbladder attacks often follow heavy meals, and they usually occur in the evening or during the night.
- Gallstone symptoms may be similar to those of other conditions.
- If gallstones are not causing symptoms, treatment is usually not needed. However, if a person has a gallbladder attack or other symptoms, a health care provider will usually recommend treatment.
- The usual treatment for gallstones is surgery to remove the gallbladder. If a person cannot undergo surgery, nonsurgical treatments may be used to dissolve cholesterol gallstones. A health care provider may use endoscopic retrograde cholangiopancreatography (ERCP) to remove stones in people who cannot undergo surgery or to remove stones from the common bile duct in people who are about to have gallbladder removal surgery.
- The gallbladder is not an essential organ, which means a person can live normally without a gallbladder. Once the gallbladder is removed, bile flows out of the liver through the hepatic and common bile ducts and directly into the duodenum, instead of being stored in the gallbladder.
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Gallstones – Diagnosis and Treatment
Gallstones are solid build-ups of crystallized bile, which is produced by the liver, stored in the gallbladder and secreted into the bowel through the bile ducts to help digest fats. Some gallstones do not produce symptoms. However, they can cause a blockage within the bile duct or gallbladder which may result in pain and inflammation, a condition called cholecystitis.
Your doctor may use abdominal CT, magnetic resonance cholangiopancreatography (MRCP), or abdominal ultrasound to help diagnose your condition. Treatment may not be necessary if you do not have symptoms. If, however, you are diagnosed with cholecystitis, your doctor may prescribe antibiotics and surgical removal of the gallbladder. If a gallstone has blocked a bile duct, your doctor may prescribe biliary interventions such as endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC) to locate and/or remove the blockage.
What are gallstones?
Gallstones are solid particles that develop in the gallbladder. Stones are formed from the crystallization of bile, a fluid made by the liver and secreted into the bowel through the bile ducts to help digest fats.
Some gallstones do not produce noticeable symptoms. However, if a gallstone causes blockage of the gallbladder or the bile duct, it can cause inflammation and pain in the right upper abdomen, upper right shoulder or between the shoulder blades, lasting from a few minutes to several hours. Other symptoms include nausea and vomiting, fever, and chills. Inflammation of the gallbladder is called cholecystitis.
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How are gallstones diagnosed and evaluated?
Imaging is used to provide your doctor with valuable information about gallstones, such as location, size and effect on organ function. Some types of imaging that your doctor may order include:
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How are gallstones treated?
Treatment of gallstones may not be necessary if you do not have symptoms. However, if you have cholecystitis, or if you are having symptoms related to gallstones, the standard treatment is intravenous antibiotics and surgical removal of the gallbladder (cholecystectomy). In most cases, your surgeon will perform a cholecystectomy laparoscopically (with endoscopes placed through small incisions in your abdomen).
If the gallstones have also caused blockage of the biliary ducts, other procedures may be performed, including:
- Endoscopic retrograde cholangiopancreatography (ERCP): ERCP is used to examine the bile ducts using an endoscope, a flexible tube that is passed from the mouth through the stomach and into the duodenum. Iodinated contrast material is injected into the bile ducts to locate gallstones that may be causing blockage. Some stones may be successfully removed during ERCP.
- Percutaneous transhepatic cholangiography (PTC): PTC is performed by making a small incision on the skin, and advancing a needle into the bile ducts. Iodinated contrast material is injected into the bile ducts to locate gallstones that may be causing blockage. Some stones can be removed during a PTC and others may be bypassed by leaving a catheter or small thin tube in place.
If your doctor decides that you are too sick to undergo surgery, there are other procedures that may be done until surgery can be performed.
- Cholecystostomy tube placement: A cholecystostomy tube is a small plastic tube (catheter) placed into your gallbladder through a small incision in the skin. The aim of this procedure is to decompress the distended, blocked and inflamed gallbladder by emptying out the backed up, under pressure bile in your gallbladder and diverting it outside the body into a bag attached to the tube. This allows decrease in pain and inflammation in the gallbladder and allows time for the antibiotics to work and for the surgery to be performed at a later date. However, it does not treat the underlying cause (the stones).
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Which test procedure or treatment is best for me?
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This page was reviewed on January, 21, 2020
Gallstones: Symptoms, clinical signs and management
Shahab Shahid MBBS
Uruj Zehra MBBS, MPhil, PhD
Last reviewed: September 07, 2020
Reading time: 9 minutes
Gallstones are hard deposits formed in the gallbladder, this is also known as cholelithiasis. If stones are seen in the common bile duct this condition is referred to as Choledocholithiasis. Gallstones can be made up of various constituents such as cholesterol, bilirubin, and mixed. Gallstones can form due to high levels of cholesterol from dietary intake. Another important factor that can contribute to gallstone formation is problems with the contraction of the gallbladder, how often and well the gallbladder empties itself. Other reasons may include, the presence of protein in the liver and bile that increases cholesterol crystallisation leading to stone formation. Gallstones are quite commonly occurring and can lead to a variety of complications.
Gallbladder (ventral view)
The gallbladder is a pear-shaped organ that is present beneath the liver. You can locate the gallbladder between the lateral aspect of the rectus abdominis muscle and the right costal margins. Its main function is to store and concentrate bile. The liver produces and releases bile, a green substance that absorbs and breaks down lipids. Bile is made up of mostly bile acid, cholesterol and bilirubin.
The gallbladder opens into the cystic duct and biliary tree. It is made up of a fundus, body and neck. The fundus is along the transpyloric plane, which is halfway between the suprasternal notch and upper border of the pubic symphysis. Other structures that cross the transpyloric plane are the L1 vertebra, neck of the pancreas, first part of the duodenum, right and left colic flexures, hila of the left and right kidneys and hilum of spleen. The neck of the gallbladder leads into the cystic duct that then connects to the common hepatic duct, which then becomes the common bile duct. The gallbladder has a section that is called the Hartmann’s pouch, this is formed from an out pouching from the neck section. The Hartmann’s pouch is a common area for gallstones to become lodged.
To master the anatomy of the gallbladder, take a look at the following resource:
Types of gallstones
The most common type of stone is made up of cholesterol, they account for around 80% of gallstones. They occur when there is a problem in the balance of levels of cholesterol, bile acids and lipids. These stones are usually yellow or green in colour and consists of cholesterol monohydrate crystals.
Pigment gallstones are another type of stone; these are made mainly from bilirubin and from the crystallization of calcium bilirubinate. The colours of pigment stones are brown or black. The brown stones are usually associated with gallbladder infection and commonly associated gram-negative bacteria are Escherichia Coli and Klebsiella. Black stones are associated with red blood cell problems for example haemolysis and liver disease.
The third type is mixed gallstone which is a subclassification of the cholesterol stones and contains at least 50% of cholesterol by weight. Gallstones are also classified by their location as intrahepatic, gallbladder and bile duct stones. Intrahepatic are more commonly brown pigment stones, gallbladder stones are predominantly cholesterol and bile duct stones are mixed type.
Common bile duct (caudal view)
Gallstones can occur due to excessive cholesterol and this can be due to diet. Risk factors include being overweight or obese, a high fat or cholesterol diet, rapid weight loss can lead to stone formation, a medical history of diabetes mellitus can put you at risk. Females are more likely to be at risk and pregnancy can contribute. A family history is linked to the condition as well. Other risk factors include liver disease for example, cirrhosis, or being over the age of 60.
A helpful mnemonic to remember the risk factors:
The Five F’s:
- In her Forties
Signs and symptoms
Gallstones present as asymptomatic majority of the time. If complications from gallstones arise then symptoms can appear.
For example in biliary colic, which occurs if the stones temporarily obstruct the cystic or common bile duct, patients experience the following signs and symptoms:
- Intermittent pain in the upper right quadrant or epigastric region.
- Pain radiates to the back.
- Certain foods evoke symptoms
Acute Cholecystitis is caused due to inflammation of gallbladder wall, signs and symptoms are as follows:
- Right upper quadrant abdominal pain is more severe and constant
- Right shoulder tip pain
- Mild jaundice may occur
- On examination gall bladder is tender
- Murphy’s sign – patient on deep inspiratory breath with palpation of the upper right quadrant feels pain
Ascending/Acute Cholangitis is an infection of bile duct most commonly due to gallstones, signs and symptoms are as follows: Hallmark of this condition is Charcot’s triad, the common findings are:
- Abdominal pain in the upper right quadrant
- Patients also can have rigors and malaise
Initial investigations to order are blood tests to measure bilirubin and liver function tests. The gold standard investigation for gallstones is abdominal ultrasound scan. Other helpful imaging tests are abdominal CT scan and gallbladder radionuclide scan. Endoscopic retrograde cholangiopancreatography (ERCP) is helpful to confirm the diagnosis of choledocholithiasis and also has a role in treatment.
Surgery is usually the first choice after diagnosis, even if the patient does not have symptoms the surgeons advise surgery to avoid complications. Laparoscopic removal of the gallbladder after giving a general anaesthesia is performed. Non-surgical treatment is an option for patients with small, radiolucent cholesterol stones. Extracorporeal shockwave lithotripsy has been used in the management of choledocholithiasis. Bile duct stones can be removed with an (ERCP). The technique used an endoscope which is inserted into the mouth, and passed down the oesophagus, and through the stomach and into the duodenum. The second part of the duodenum is where the sphincter of oddi is located. The ampulla of vater is accessed via the sphincter of oddi, and the scope is passed up the biliary tree. MRCP (magnetic resonance cholangiopancreatography) is less invasive and many clinicians prefer to have this performed before an ERCP. The ERCP procedure can visualise the biliary system and remove any stones if present and insertion of stents to allow for the ducts to remain open is possible too.
Common bile duct (ventral view)
Lifestyle changes are very important to advise patients on. Dietary advice is important; meal plans can be advised to encourage eating several times a day to replace large meals. Reducing fat in diet is crucial and increasing fibre can be helpful too. Avoiding food and drink that has a laxative effect like caffeine and sugary foods, is useful, as after treatment of gall bladder removal patients may experience watery diarrhoea.
Gallstone ileus is a complication of a gangrenous gallstone. A fistula forms between the gallbladder and duodenum this allows for the stone to enter the intestines. Once the gallstone reaches a diameter of more than 2.5cm, there is a risk of intestinal obstruction.
Gallstone pancreatitis is another potential complication that can occur if the gallstone is passing through the bile duct and becomes lodged in the Sphincter of Oddi.
Choledocholithiasis occurs if the gallstone are formed within the common bile duct that leads to obstruction and infection. This can be life-threatening and emergency medical care is required. Patients may present with abdominal pain, fever, jaundice, anorexia, nausea and vomiting. Transabdominal ultrasound scan is recommended to examine the gallbladder and surrounding structures. To treat stone extraction is needed, lithotripsy is an option where the stone is fragmented or surgery by removing the gallbladder with a cholecystectomy. Stenting can be done to the common bile duct to provide drainage and prevention of future obstruction.
- Gallstones can be divided into three main types: Cholesterol stones, pigment stones and mixed.
- Gallstones are usually asymptomatic.
- Risk factors are being female, overweight and a positive family history.
- It can lead to complications such as biliary colic, acute cholecystitis and ascending cholangitis.
- Biliary colic presents with intermittent right upper quadrant pain.
- Acute cholecystitis presents with right upper quadrant pain, radiating to the shoulder tip, mild jaundice, nausea, vomiting. Murphy’s sign is positive.
- Ascending cholangitis presents with Charcot’s triad: right upper quadrant abdominal pain, jaundice and fever.
- The main investigation of diagnosis of gallstones is abdominal ultrasound scan.
- Gallstones can either pass themselves, or medically can be treated with ursodeoxycholic acid and surgically by laparoscopic cholecystectomy.
- Lifestyle changes are advised to patients, for example a healthier diet is important to implement.
- Potential complications of untreated gallstones are gallstone ileus, gallstone pancreatitis and choledocholithisais.
Gallbladder – gallstones and surgery
The gallbladder is a small sac that holds bile, a digestive juice produced by the liver that is used in the breakdown of dietary fats. The gallbladder extracts water from its store of bile until the liquid becomes highly concentrated. The presence of fatty foods triggers the gallbladder to squeeze its bile concentrate into the small intestine.
Gallstones (biliary calculi) are small stones made from cholesterol, bile pigment and calcium salts, usually in a mixture that forms in the gallbladder. They are a common disorder of the digestive system, and affect around 15 per cent of people aged 50 years and over.
Some things that may cause gallstones to form include the crystallisation of excess cholesterol in bile and the failure of the gallbladder to empty completely.
In most cases, gallstones don’t cause any problems. However, you might need prompt treatment if stones block ducts and cause complications such as infections or inflammation of the pancreas (pancreatitis).
Surgeons may remove your gallbladder (called a cholecystectomy) if gallstones (or other types of gallbladder disease) are causing problems. Techniques include laparoscopic (‘keyhole’) cholecystectomy or open surgery. The gallbladder is not a vital organ, so your body can cope quite well without it.
Symptoms of gallstones
In approximately 70 per cent of cases, gallstones cause no symptoms. The symptoms of gallstones may include:
- pain in the abdomen and back. Pain is generally infrequent, but severe
- increase in abdominal pain after eating a fatty meal
- fever and pain, if the gallbladder or bile duct becomes infected.
Types of gallstones
There are three main types of gallstones being:
- mixed stones – the most common type. They are made up of cholesterol and salts. Mixed stones tend to develop in batches
- cholesterol stones – made up mainly of cholesterol, a fat-like substance that is crucial to many metabolic processes. Cholesterol stones can grow large enough to block bile ducts
- pigment stones – bile is greenish-brown in colour, due to particular pigments. Gallstones made from bile pigment are usually small, but numerous.
Causes and risk factors for gallstones
Gallstones are more common in women than in men. They are also more common in overweight people and people with a family history of gallstones.
There is no single cause of gallstones. In some people, the liver produces too much cholesterol. This can result in the formation of cholesterol crystals in bile that grow into stones. In other people, gallstones form because of changes in other components of bile or because the gallbladder does not empty normally.
Diagnosis of gallstones
Doctors diagnose gallstones by using a number of tests, including:
- general tests – such as physical examination and x-rays
- ultrasound – soundwaves form a picture that shows the presence of gallstones
- endoscope test – endoscopic retrograde cholangiopancreatography (ERCP). A thin tube is passed through the oesophagus and injects dye into the bowel to improve the quality of x-ray pictures
- hepatobiliary iminodiacetic acid (HIDA) scan – a special type of nuclear scan that assesses how well the gallbladder functions
- magnetic resonance cholangiopancreatography (MRCP) – a form of the body-imaging technique magnetic resonance imaging (MRI). The person’s liver, biliary and pancreatic system is imaged using an MRI unit. The image is similar to an ERCP test.
Complications of gallstones
If gallstones cause no symptoms, you rarely need any treatment.
Complications that may require prompt medical treatment include:
- biliary colic – a gallstone can move from the body of the gallbladder into its neck (cystic duct), leading to obstruction. Symptoms include severe pain and fever
- inflammation of the gallbladder (cholecystitis) – a gallstone blocks the gallbladder duct, leading to infection and inflammation of the gallbladder. Symptoms include severe abdominal pain, nausea and vomiting
- jaundice – if a gallstone blocks a bile duct leading to the bowel, trapped bile enters the person’s bloodstream instead of the digestive system. The bile pigments cause a yellowing of the person’s skin and eyes. Their urine may also turn orange or brown
- pancreatitis – inflammation of the pancreas, caused by a blocked bile duct low down near the pancreas. Pancreatic enzymes irritate and burn the pancreas and leak out into the abdominal cavity
- cholangitis – inflammation of the bile ducts, which occurs when a bile duct becomes blocked by a gallstone and the bile becomes infected. This causes pain, fever, jaundice and rigors (shaking)
- infection of the liver
- cancer of the gallbladder (occurs rarely).
Treatment for gallstones
Gallstones that cause no symptoms, generally don’t need any medical treatment. In certain cases (such as abdominal surgery for other conditions), doctors may remove your gallbladder if you are at high risk of complications of gallstones.
Treatment depends on the size and location of the gallstones, but may include:
- dietary modifications – such as limiting or eliminating fatty foods and dairy products
- lithotripsy – a special machine generates soundwaves to shatter the gallstones. This treatment is used in certain centres only, for the minority of people with small and soft stones
- medications – some medications can dissolve gallstones, but this treatment is only rarely given, due to side effects and a variable success rate
Surgical removal of the gallbladder or gallstones
Around 80 per cent of people with gallstone symptoms will need surgery. Surgeons may remove your entire gallbladder (cholecystectomy), or just the stones from bile ducts.
Techniques to remove the gallbladder include:
- laparoscopic cholecystectomy – ‘keyhole’ surgery. The surgeon makes a number of small incisions (cuts) through the skin, allowing access for a range of instruments. The surgeon removes the gallbladder through one of the incisions
- open surgery (laparotomy) – the surgeon reaches the gallbladder through a wider abdominal incision. You might need open surgery if you have scarring from prior operations or a bleeding disorder.
Medical factors to consider before cholecystectomy
Before the operation, you need to discuss some things with your doctor or surgeon, including:
- your medical history, since some pre-existing conditions may influence decisions on surgery and anaesthetic
- any medications you take on a regular basis, including over-the-counter preparations
- any bad reactions or side effects from any medications.
The general procedure includes:
- The surgeon makes a number of small incisions into your abdomen, so that slender instruments can reach into the abdominal cavity.
- A tube blowing a gentle stream of carbon dioxide gas is inserted. This separates the abdominal wall from the underlying organs.
- The surgeon views the gallbladder on a TV monitor by using a tiny camera attached to the laparoscope.
- Special x-rays (cholangiograms) during the operation can check for gallstones wedged in the bile ducts.
- The ducts and artery that service the gallbladder are clipped shut. These clips are permanent.
- The gallbladder is cut free using either laser or electrocautery
- The gallbladder, along with its load of gallstones, is pulled out of the body through one of the abdominal incisions.
- The instruments and the carbon dioxide gas are removed from the abdominal cavity. The incisions are sutured (closed up) and covered with dressings.
Open gallbladder surgery
The general procedure is the same as for laparoscopic surgery, except that the surgeon reaches the gallbladder through a large, single incision in the abdominal wall. Sometimes, an operation that starts out as a laparoscopic cholecystectomy turns into open surgery if the surgeon encounters unexpected difficulties, such as not being able to see the gallbladder properly.
Immediately after gallbladder surgery
After a gallbladder operation, you can expect to:
- feel mild pain in your shoulder from the carbon dioxide gas
- receive pain-relieving medications
- be encouraged to cough regularly to clear your lungs from the general anaesthetic
- be encouraged to walk around as soon as you feel able
- stay overnight in hospital, if you had a laparoscopic cholecystectomy
- stay up to eight days in hospital, if you had open surgery.
Complications after gallbladder surgery
All surgery carries some degree of risk. Possible complications of cholecystectomy include:
- internal bleeding
- injury to nearby digestive organs
- injury to the bile duct
- leakage of bile into the abdominal cavity
- injury to blood vessels.
Self-care after gallbladder surgery
Be guided by your doctor, but general self-care suggestions include:
- Rest as much as you can for around three to five days.
- Avoid heavy lifting and physical exertion.
- Expect your digestive system to take a few days to settle down. Common short-term problems include bloating, abdominal pains and changes to toilet habits.
Most people recover within one week of laparoscopic surgery.
Long-term outlook after gall bladder surgery
You will need to see your doctor between seven and 10 days after surgery to make sure all is well. Some rare complications may have to be followed up with another operation.
Where to get help
- Your doctor
- NURSE-ON-CALL Tel. 1300 60 60 24 – for expert health information and advice (24 hours, 7 days)
Things to remember
- Gallstones are small stones made from cholesterol, bile pigment and calcium salts, which form in a person’s gall bladder.
- Medical treatment isn’t necessary unless the gallstones cause symptoms.
- Treatment options include surgery and shattering the stones with soundwaves.
how to detect stones in the gallbladder using ultrasound
Cholelithiasis (GSD) is a pathology associated with the formation of stones (calculi) in the lumen of the gallbladder or ducts. For a long time, stone formation may not manifest itself clinically, symptoms appear only when the stone blocks the lumen of the duct and jaundice develops. In other cases, gallstones may be accompanied by subjective discomfort in the right hypochondrium, and sometimes cause an acute attack of cholecystitis.
Most stones become an accidental diagnostic finding during examination for other diseases, only a quarter of patients complain of recurrent or acute abdominal pain. The simplest, but informative method for detecting calculi in the biliary tract is an ultrasound examination of the abdominal organs, which allows you to determine the state of the gallbladder and ducts, as well as determine the size and location of stones.
Gallbladder and ducts: norm and pathology on ultrasound
On ultrasound scanning, the gallbladder looks like an elongated, pear-shaped sac. Its position, shape and size are variable. In the structure of the organ, the bottom, body and neck are distinguished.
The thickness of the gallbladder wall is normally no more than 3 mm when examined on an empty stomach, and with tight bile filling (after eating, especially fatty) – 1 mm. Its thickening may indicate the presence of an inflammatory process, the cause of which can be both diseases of the organ itself (acute or chronic cholecystitis) and other pathologies (heart failure, liver disease, a decrease in the level of protein in the blood, etc.). An acute inflammatory process in the gallbladder is spoken of in cases when a small amount of fluid is visualized around it, and the organ wall itself becomes heterogeneous, “loose”.
The neck of the bladder smoothly passes into the cystic duct, it later merges with the common hepatic duct and forms a common bile duct (common bile duct, ductus choledochus). In turn, the common bile duct opens into the lumen of the duodenum in the region of the large duodenal papilla, where bile enters. The normal diameter of the common bile duct in the initial sections is no more than 6 mm.
Stones are formed in the gallbladder due to changes in the composition of the secreted bile. During ultrasound scanning, they are defined as bright structures from which an acoustic shadow leaves, while the bubble itself often increases in size and becomes stretched. The number, size and location of stones in the bladder can vary widely. In cases where the organ is 100% filled with calculi, they speak of a “disabled” gallbladder, i.e.That is, he is no longer capable of performing his functions.
Stones change their position in the bladder depending on the position of the patient’s body. To determine the displacement of the stone and to carry out a differential diagnosis with a parietal polyp, the ultrasound doctor performs an examination in several positions of the patient: lying on his back, on his left side. However, some stones can be tightly fixed to the wall of the gallbladder due to the pronounced inflammatory process around.
Especially dangerous are stones that are wedged into the neck area or are localized in the lumen of the common bile duct, this can cause obstructive jaundice – a condition in which the natural outflow of bile into the duodenum is disrupted and the body becomes intoxicated with bilirubin.
Preparation for ultrasound of the abdominal cavity.
3 days before the study, it is necessary to exclude gas-forming products from the diet: black bread, fresh vegetables and fruits, juices, legumes, dairy products, alcohol, carbonated drinks, sweet bakery products.
The last meal before the examination should be light and no later than 8-12 hours before the procedure.
Do not drink fluids 3 hours before the examination.
If there is a problem with increased gas production or constipation: 2 days before the ultrasound, we recommend taking the drug “Espumisan” (2 times a day, one capsule) or activated charcoal (2 times a day, 4 tablets). In case of constipation 1 day before the examination, cleanse the intestines: put an enema or take a mild laxative, or put a glycerin candle, or use the Mikrolax micro enema.
In case of an acute pain attack, the study is carried out without any preparation.
If calculus is detected in the lumen of the gallbladder, you should consult a gastroenterologist. There are two types of treatment tactics: conservative and surgical.In the first case, the patient should constantly adhere to a special diet (fatty, smoked, fried, coffee, cocoa, chocolate and some other products are excluded from the diet) and special preparations may be prescribed to dissolve stones. If conservative therapy is ineffective, surgical intervention is performed.
Operations are of several types and depend on the location of the stones. In cases where calculi are in the gallbladder, laparoscopic or open cholecystectomy is performed – removal of the gallbladder. If the stone is located in the bile duct, one of the varieties of papillosphincterotomy (dissection of the large duodenal papilla) or choledochotomy (dissection of the common bile duct and removal of calculus) is performed.
Choledocholithiasis: stones in the bile ducts operation
Choledocholithiasis is one of the forms of manifestation of gallstone disease, in which calculi are found not in the gallbladder, but in the bile ducts. Most often – in the common bile duct, common bile duct.
Moreover, they either get there from the gallbladder, or are formed directly in the common bile duct. As a rule, the treatment of such a disease is prompt. Note that the disease is quite serious, especially in those cases when serious complications develop in the form of a blockage of the duct, then the patient’s life is threatened.
How do stones appear in the bile duct?
They usually form in the gallbladder and travel with the flow of bile through the cystic duct. At the same time, the general appearance of stones in the bladder and in the ducts, their microstructure and chemical composition are identical. Evidence of the gallbladder origin of calculi is the presence of edges on their surface, which are formed as a result of the contact of several stones in the gallbladder. The wider the diameter of the cystic duct, the greater the likelihood of stones moving into the common bile duct. In some cases, stone formation can occur directly in the lumen of the common bile duct itself. This occurs when the outflow of bile through the ducts is difficult.
The reasons for the formation of stones in the biliary tract can be:
- Stenosis of the terminal (end) section of the common bile duct.
- Penetration from the duodenum of some helminths (roundworm, cat’s fluke).
- Production of bile with particularly high lithogenic properties in some geographic regions (the so-called Far Eastern choledocholithiasis). The mechanism for the formation of such bile is still unknown. In these cases, choledocholithiasis is considered primary.
- Sometimes stones in the bile ducts are detected some time later (several months, sometimes several years) after a cholecystectomy performed earlier. These can be stones not detected before the operation and during its execution (“residual” or “forgotten”), and newly formed (“recurrent” choledocholithiasis), which formed in the bile ducts after surgery due to metabolic disorders, stagnation of bile or the presence of infection.
Diagnosis of choledocholithiasis (stones in the bile ducts)
Diagnosis of choledocholithiasis cannot be based only on the clinic.Vesiculate stones in the common bile duct are not always clinically detected, and may be asymptomatic for a long time. Only the appearance of an attack of hepatic colic followed by jaundice suggests a possible problem in the biliary tract. The nature of hepatic colic in choledocholithiasis is no different from that emanating from the gallbladder. Although sometimes pain can be localized somewhat higher and more medial than with cholecystolithiasis, in the epigastric region. Even less often, there is unbearable pain in the event of a sudden blockage of the duodenal papilla with a stone (the so-called “papillary ileus”).
In the presence of small (less than 5-7 mm) stones in the gallbladder in any patient with gallstone disease, the presence of stones in the common bile duct should be suspected, since such sizes allow them to migrate freely through the cystic duct. You should especially be on your guard with bilirubinemia (even a slight increase in serum bilirubin). Usually, the level of alkaline phosphatase rises at the same time, an increase in the level of aminotransferases is likely. However, after the obstruction (blockage) has been removed, aminotransferase levels usually return to normal quickly.While bilirubin levels often remain elevated for 2 weeks, elevated alkaline phosphatase levels remain even longer.
Asymptomatic choledocholithiasis may not be accompanied by changes in laboratory tests. With the development of inflammation in the blood, the level of leukocytes and ESR increases. If the outflow of bile is disturbed, an increase in the concentration of bilirubin (due to the direct fraction), an increase in the level of aminotransferases (transaminases) and alkaline phosphatase in the biochemical analysis of blood are observed, and the content of bile pigments in urine increases.Stercobilin may be absent in the feces. A very formidable laboratory symptom is an increase in blood amylase, as this indicates damage to the pancreas.
Ultrasound examination of the abdominal organs (ultrasound) is the most accessible method for examining the biliary tract, essentially a screening method. Its sensitivity for detecting the expansion of the common bile duct is up to 90%. However, it is not always possible for a specialist in ultrasound diagnostics to examine the terminal section of the common bile duct (the zone of confluence of the common bile and pancreatic ducts, and their confluence into the duodenum), i. e.That is, the department is very important for making the correct diagnosis. The examination can interfere with gas or liquid (even in small quantities) in the intestine.
Therefore, in many cases, you have to resort to additional methods:
- Endoscopic ultrasound (endosonography). Examination is carried out with a special endosonographic probe through the lumen of the stomach and duodenum. With such an examination, the efficiency of correct diagnosis increases to 85-100%.
- MPT cholangiography. The accuracy of this research method is up to 97%. When performing MRI cholangiography, an image of the gallbladder and cystic duct, segmental, lobar bile ducts, common hepatic duct, common bile duct and pancreatic duct is obtained. It becomes possible to accurately visualize stones in the lumen of the ducts, their narrowing or expansion. The great advantages of MRI cholangiography include its non-invasiveness and the absence of the need for the use of contrast agents.
The following two diagnostic methods are invasive, therefore, they can only be used when the patient is in the hospital. We are talking about endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PCCG).
- ERCP – a standard method for diagnosing choledocholithiasis, in the hands of an experienced endoscopist, it is effective in 90 – 95% of cases. However, this method is associated with the possible development of serious complications: hyperamilasemia, cholangitis, pancreatitis, retroperitoneal perforation of the duodenum, bleeding.Therefore, its use must be justified.
- Percutaneous transhepatic cholangiography is used in patients with obstructive jaundice when it is impossible to perform retrograde cholangiopancreatography. In this case, under the control of an ultrasound or X-ray unit, an expanded duct of the right or left lobe of the liver is punctured through the skin. After the evacuation of bile, a contrast agent is injected into the lumen of the bile duct and a series of images is taken. This allows you to get a clear image of the biliary tract, determine the cause of obstructive jaundice and the level of obstruction.
Additional examination methods include computed tomography and video duodenoscopy.
- Computed tomography (CT) of the abdominal cavity is used if there is a suspicion of compression of the bile ducts from the outside, or the presence of a neoplasm in their lumen.
- Video duodenoscopy – endoscopic examination, in which a special endoscope with lateral optics is used, which allows a good examination of the area of the large duodenal papilla or “papilla of Vater” (the place where the bile ducts enter the duodenum).This is a very important study, since sometimes the cause of choledocholithiasis is the pathology of the Vater papilla (inflammation, cicatricial stricture, tumor, or wedged calculus).
Main manifestations of choledocholithiasis
Attack of biliary colic.
Concrements in hepaticoholedochus injure its wall. Damage to the mucosa occurs especially easily in the narrowest part – in the area of the large duodenal papilla.Therefore, the main and most striking symptom of hepatic colic is pain. The sensation of pain in choledocholithiasis practically does not differ from colic in cholecystolithiasis. Its irradiation to the back or lower back is characteristic. The pain can become shingles in the event that the overlap with calculus occurred in the area of the Vater papilla, located in the duodenum 12. In this case, there is a violation of the outflow of both bile and pancreatic juice, as a result, the pancreas suffers.
Mechanical (subhepatic) jaundice.
When the stones obstruct the duct, the pressure rises in the biliary tract, the latter expand, but the blockage by the stone prevents the flow of bile into the intestinal tube, the so-called acholic stool (clarification of feces) and dark urine (beer-colored) appear.
Thus, obstructive jaundice develops. Difficulty in the outflow of bile through the biliary tract leads to the fact that bilirubin appears in the blood – a bile pigment with which the tissues of a sick person are saturated.Human skin, sclera, mucous membranes become yellow.
However, complete blockage and persistent jaundice with choledocholithiasis are not so common. At the same time, any obstacle to the outflow of bile creates favorable conditions for the development of infection and inflammation in the ducts. There is cholangitis , which easily develops against the background of damage to the mucous membrane. As a result of repeated trauma and inflammation, narrowing of the lumen of the duct along its length and in the region of the large duodenal papilla can form – stenosing cholangitis and papillitis.The spread of the inflammatory process upward, towards the liver, can lead to a serious complication: cholangiogenic liver abscess. It should also be noted that the diameter of the common bile duct, of course, reflects the state of hypertension in it, but this is not always the case – with narrow ducts, choledocholithiasis can also form. The inflammatory process is manifested by an increase in body temperature, chills, and itchy skin. Cholangitis is typically accompanied by septic fever.Less typical for choledocholithiasis are small temperature peaks accompanying attacks of pain.
With latent choledocholithiasis , a complaint of dull pain under the right costal arch is characteristic.
With dyspeptic form of choledocholithiasis , the patient complains of uncharacteristic pressing pain under the right costal arch or in the epigastric region, dyspepsia, nausea, belching, gas and intolerance to fatty foods.
More about complications of choledocholithiasis
1. Cholangitis. As mentioned earlier, in the presence of stones in the bile ducts, the infection has the conditions for its development, this leads to inflammation – cholangitis. When this complication occurs, a high temperature appears with chills and torrential sweats, severe pain in the right hypochondrium, nausea, vomiting. severe general weakness. The danger of this complication is associated with the fact that against the background of the developing infection, liver function is impaired.In addition, if treatment is not carried out in a timely manner, there is a danger of the formation of a liver abscess, as mentioned above, and in the future – the development of general sepsis and liver failure.
2. Jaundice . Always stagnant. The blockage is usually incomplete and the intensity of the increase in bilirubin fluctuates. Suspicious of choledocholithiasis should be not only any jaundice against the background of hepatic colic, but also fleeting subicterus, especially if it is often repeated.However, even severe choledocholithiasis does not always manifest itself as jaundice. Kehr also noted that sometimes when stones are piled up, bile, “like a mountain stream, freely pours over the stones.” More than 1/3 of patients with choledocholithiasis do not have jaundice. Much less often there is a manifestation of jaundice without accompanying biliary colic.
3. Acute pancreatitis. The common bile duct and pancreatic duct in humans in 70% of cases merge into one channel and together flow into the duodenum.When this common canal is blocked by a stone (this usually happens at the site of exit into the duodenum), then both bile and pancreatic enzymes lose the ability to be secreted into the intestines. There is an increase in pressure in the bile and pancreatic ducts, which leads to a serious complication – acute pancreatitis. Acute inflammation of the pancreas is a very serious illness, often fatal. Immediate surgical treatment is required in order to remove this obstacle, as well as other therapeutic measures.
Stones in the bile ducts – operation
Treatment of choledocholithiasis can only be surgical. However, this does not mean that a large operation with a large incision in the abdomen must be performed.
Most often, with choledocholithiasis, the removal of calculi of the bile ducts is carried out endoscopically.
In the hospital, the patient undergoes ERCP to clarify the presence of a stone, its localization and other parameters.If the diagnosis of choledocholithiasis is confirmed, this study turns from diagnostic to therapeutic. Dissection of the narrowed zone of the Vater’s papilla (papillosphincterotomy), crushing of stones (lithotripsy) or their removal (extraction) is performed. The surgeon’s tactics depend on the size of the stone. Stones more than 2 cm are usually crushed, less than 1 cm more often go away on their own within 2 days. But as practice shows, in most cases, in order to remove or ensure the independent passage of stones, one has to resort to endoscopic papillosphincterotomy.This is rarely avoided.
When it is impossible to remove the stone endoscopically, they resort to surgery. The operation is performed by the classical method or by laparoscopy. During the operation, the common bile duct is dissected (choledochotomy) with a special instrument and the stones are removed. In all cases of choledocholithiasis treatment, the gallbladder is removed at the same time (if it has not been removed earlier). In the future, after surgical treatment, it is necessary to undergo a postoperative examination, follow the recommendations on the regimen, diet and medication, which will be prescribed by the attending physician in the hospital.
In any case, the tactics of examination and treatment should be determined by a specialist and directed from simple methods of diagnosis and treatment to more complex ones.
Our Clinic provides a full range of diagnostics, surgical and endoscopic treatment of gallstone disease and its complications. Surgical treatment in most cases is minimally invasive using laparoscopic and endoscopic technologies.
Prevention of gallstone disease – GUZ TO Tula Regional Clinical Hospital
Cholelithiasis is a disease characterized by a disorder in the synthesis and circulation of bile in the hepatobiliary system as a result of impaired cholesterol or bilirubin metabolism, as a result of which stones (calculi) are formed in the bile ducts and gallbladder.Gallstone disease is dangerous by the development of severe complications with a high probability of death.
Risk factors for the development of gallstone disease are: old and senile age, taking medications that interfere with the metabolism of cholesterol and bilirubin, genetic factors, nutritional disorders (obesity, sudden weight loss, fasting, high cholesterol and high-density blood lipoproteins, hypertriglycerolinemia), multiple pregnancies, metabolic diseases, diseases of the gastrointestinal tract, postoperative conditions (after resection of the stomach, stem vagectomy).
Cholelithiasis is much more common in women.
The reasons for the formation of stones.
In case of violation of the quantitative ratio of bile components in the body, solid formations (flakes) are formed, which, with the course of the disease, grow and merge into stones. The most common cholelithiasis is with impaired cholesterol metabolism (excess cholesterol content in bile). Bile oversaturated with cholesterol is called lithogenic.
Excess cholesterol is formed due to the following factors:
- for obesity and the consumption of large amounts of cholesterol-containing foods;
- with a decrease in the amount of bile acids entering the bile;
- with a decrease in the amount of phospholipids, which, like bile acids, prevent cholesterol and bilirubin from solidifying and settling;
- with stagnation in the bile circulation system (thickening of bile due to the absorption of water and bile acids in the gallbladder).
Stagnation of bile, in turn, can be of a mechanical and functional nature. With mechanical stagnation, there is an obstacle to the outflow of bile from the bladder. Functional disorders are associated with a disorder of the motility of the gallbladder and biliary tract.
Also, infections, inflammation of the organs of the biliary system, allergic reactions, and autoimmune conditions can lead to the development of gallstone disease.
Clinical manifestations of gallstone disease.
A characteristic pain symptom in cholelithiasis is biliary or hepatic colic – pronounced acute, sudden pain under the right rib of a cutting, stabbing nature.After a couple of hours, the pain finally concentrates in the area of the projection of the gallbladder. It can radiate to the back, under the right shoulder blade, to the neck, to the right shoulder. Sometimes irradiation to the heart area can cause angina pectoris.
Pain most often occurs after eating spicy, spicy, fried, fatty foods, alcohol, stress, heavy physical exertion, prolonged work in an inclined position. The reasons for the development of pain syndrome are spasm of the muscles of the gallbladder and ducts as a reflex response to irritation of the wall by calculi and as a result of hyperextension of the bladder with excess bile in the presence of obstruction in the biliary tract.
Depending on the severity of intoxication, there is an increase in temperature from subfebrile numbers to severe fever. With blockage of the common bile duct by calculus and its obstruction, obstructive jaundice and discoloration of feces are observed.
Complications of gallstone disease.
The most common complication of cholelithiasis is inflammation of the gallbladder (acute and chronic) and obstruction of the biliary tract with calculus. Blockage of the bile duct in the pancreas can cause acute biliary pancreatitis.Also, a common complication of gallstone disease is inflammation of the bile ducts – cholangitis.
Treatment of gallstone disease.
If acute or chronic calculous cholecystitis develops, removal of the gallbladder is indicated as a source of stone formation. Surgical intervention (cholecystotomy) is cavitary or laparoscopic, depending on the state of the body, pathological changes in the walls of the bladder and surrounding tissues, the size of calculi.
There are methods for dissolving calculi with the help of ursodeoxycholic and chenodeoxycholic acids, but this kind of therapy does not lead to a cure for gallstone disease and, over time, the formation of new stones is possible. Taking drugs that increase the secretion of bile in the presence of calculi in the bladder is contraindicated.
Prediction and prevention of gallstone disease.
Prevention of cholelithiasis consists in avoiding factors contributing to increased cholesterolemia and bilirubinemia, bile stagnation.A balanced diet, normalization of body weight, an active lifestyle with regular physical activity allow avoiding metabolic disorders, and timely detection and treatment of pathologies of the biliary system (dyskinesias, obstructions, inflammatory diseases) can reduce the likelihood of bile stasis and sedimentation in the gallbladder. Particular attention should be paid to the metabolism of cholesterol and the state of the biliary system to persons with a genetic predisposition to stone formation.
In the presence of stones in the gallbladder, the prevention of attacks of biliary colic will be following a strict diet (excluding fatty, fried foods, muffins, pastry creams, sweets, alcohol, carbonated drinks, etc.).normalization of body weight, intake of a sufficient amount of fluid. To reduce the likelihood of movement of stones from the gallbladder along the ducts, work associated with a prolonged stay in an inclined position is not recommended.
The prognosis of the development of gallstone disease directly depends on the rate of formation of stones, their size and mobility. In the overwhelming majority of cases, the presence of stones in the gallbladder leads to the development of complications. With successful surgical removal of the gallbladder – a cure without pronounced consequences for the quality of life of patients.
Operations on the gallbladder, biliary tract and pancreas
For whom is gallbladder removal indicated?
We perform removal of the gallbladder in the presence of stones (calculi) in it and in the presence of gallbladder polyps.
The operation is indicated in all patients with stones with clinical manifestations (attacks of pain, dull pain and discomfort in the hypochondrium, nausea and intolerance to fatty foods) and a complicated course of cholelithiasis (attacks of acute cholecystitis, pancreatitis, obstructive jaundice, stones in the bile ducts and etc.).
With an asymptomatic course of gallstone disease, prophylactic cholecystectomy can now be performed to prevent its complications of stone bearing, especially in the presence of small stones in the gallbladder and in persons of certain professions and lifestyles (long business trips, expeditions, etc.). Prophylactic removal of the gallbladder is possible in the absence of a high risk of surgery due to the use of laparoscopy.
Why is it better to perform the operation at the Grand Medica center?
Our center uses three laparoscopic techniques – classic laparoscopic cholecystectomy, minilaparoscopic cholecystectomy, cholecystectomy through a single laparoscopic approach (SILS – single incision laparoscopic surgery).Operations are performed at an expert level using equipment from the German company Karl Storz.
The technique of laparoscopic cholecystectomy in our center is performed in accordance with the clinical guidelines of the European Society of Endoscopic Surgeons for the prevention of bile duct injuries.
Regardless of the method of removing the gallbladder during surgery, in real time, in our center, if there are clinical indications, examination of the bile ducts by the method of cholangiography using the C-arm is carried out, which allows, if necessary, to perform a one-stage elimination under anesthesia of pathological changes in the bile ducts (stones, constrictions) by using the technique of antegrade endoscopic papillosphincterotomy.
Cholangiography is a mandatory method of intraoperative examination of the bile ducts for indications of jaundice, dilation of the ducts, previous attacks of pancreatitis, girdle pain – especially in patients with small stones in the gallbladder. An alternative, highly informative, painless and safe method of examining the bile ducts is magnetic resonance imaging (MRI cholangiography), which is performed in our center before the operation and can be performed in most patients.
This method allows the surgeon to know about possible anomalies in the structure of the bile ducts and the presence of pathological changes before the operation. MRI cholangiography avoids radiation exposure during surgery by eliminating cholangiography. The duration of a comfortable stay in the hospital after a low-traumatic method of removing the gallbladder, as a rule, is 2-3 days. Classical laparoscopic cholecystectomy is a generally accepted technique in the world, it is performed under general anesthesia through four approaches, length from 6 mm to 10 mm with the expansion of one of the approaches to 20-40 mm to extract the gallbladder.
Figure – Conditional scheme of the location and size of punctures in classical laparoscopic gallbladder removal
Minilaparoscopic cholecystectomy is performed with instruments with an outer diameter of 3 to 5 millimeters; removal of the gallbladder is performed through the umbilical access. This technique is exclusive in its least traumatic effect and leaves hardly noticeable postoperative scars, as it is performed using ultra-small punctures (approaches).
Figure – Conditional scheme of the location and size of punctures in minilaparoscopic cholecystectomy
Cholecystectomy through a single laparoscopic approach allows you to save the patient from cholelithiasis through an inconspicuous access in the area of the skin fold of the navel 2.5-3 cm long.The technique has the greatest cosmetic advantages over other methods of removing the gallbladder and is advisable in patients with large stones in the gallbladder more than 2 centimeters, as well as when combined with an umbilical hernia.1-2 years after this technique, an inconspicuous postoperative scar is formed along the skin fold of the navel in most patients.
Figure – Postoperative scar in the navel after a single laparoscopic approach
Cholecystectomy through a mini-access is performed in patients with a high anesthetic risk and concomitant diseases, in which the use of laparoscopy is contraindicated. The mini-access length for most patients is 4 to 8 cm.The course of the postoperative period with cholecystectomy through a mini-access differs little from the laparoscopic method of operation.
Removal of stones from the bile ducts
Cholangiolithiasis is a frequent manifestation of gallstone disease. Stones inside the gallbladder form in 16% of the entire adult population. In 15% of them, calculi are also found inside the bile ducts. This condition is very dangerous because it causes a number of complications:
- Obstructive jaundice
- Purulent cholangitis
- Biliary pancreatitis
Many cases of the disease require emergency surgery.There are several types of surgery that can remove stones from the bile ducts.
Types of operations
Today, in all developed countries, minimally invasive surgical interventions on the gallbladder and ducts are preferred. Surgical access is performed in one of two ways:
- Through the abdominal wall
- Through the gastrointestinal tract
Access through the abdominal wall can be laparotomic, minilaparotomic or laparoscopic.A laparotomy means an incision is made in the abdominal wall where surgical instruments and the surgeon’s hands can enter. This type of operation is rarely used. It is used either in countries with poorly developed medicine, or when laparoscopic access is impossible for some reason. Such reasons may be:
- Significant infiltration in the area of the gallbladder and ducts
- Sclerotic changes in the gallbladder
- Location of the gallbladder inside the liver in cirrhosis, echinococcosis
- Fistulas (pathological connections of the gallbladder with the abdominal cavity or adjacent organs)
- Sclerosis of the biliary tract
In these cases, minimally invasive surgery is difficult, or there is a high risk of damage to the biliary tract.Therefore, the intervention is carried out in the traditional way.
In other cases, laparoscopy is performed. The doctor inserts the camera and surgical instruments through minimal incisions. With the help of manipulators, he controls the tools, and gets an overview thanks to the lighting, the camera and the image on the monitor.
All clinics in Western countries use endoscopic retrograde surgery. Access is through the gastrointestinal tract. It is called transapillary because the doctor inserts the instruments through the large duodenal papilla.The bile ducts open into the duodenum. Through it, the doctor enters the biliary system, after which he performs all the necessary manipulations under the control of a video camera.
The doctor passes through the large duodenal papilla in one of two ways:
- Papillosphincterotomy – its dissection
- Papillosphincterodilation – expansion
In the future, in each case, it is individually decided how to remove the stones. Lithoextraction (extraction of calculi) or lithotripsy (their crushing) can be performed.It depends on the size and density of the stones. If necessary, crushing is performed mechanically, electrohydraulically, or with a laser.
Benefits of treatment in Germany
The doctors of German clinics have a high level of qualifications. Therefore, they perform transapillary operations to remove gallstones in the ducts even in difficult cases, when the patient has:
- Part of the stomach is removed
- An inflammatory process of the large duodenal papilla has developed
- Cholecysto-duodenal fistulas are present
- Inconveniently located papilla
- There are signs adenomas or diverticulum
If you are undergoing treatment in Germany, the risk that the doctor decides to take the simpler route and perform a laparotomy operation is zero.Minimally invasive interventions are always a priority. Because they are less traumatic for the patient, carry lower risks, provide an easier course of the postoperative period, and give much fewer complications. In addition, during the operation through the papillary access, no scars remain on the abdominal wall.
Safety of the operation is of no small importance. Despite the fact that endoscopic transapillary intervention does not involve dissection of the anterior abdominal wall, this manipulation carries a certain risk of complications.Among them:
- Bleeding – observed in 2-3% of patients
- Inflammation of the bile ducts – in 1-3% of patients
- Duct perforation during surgery – 0.5-2% of cases
- Acute pancreatitis – from 1 up to 10% of cases in different clinics
The risk of complications depends on the skill of the surgeon, the technical equipment of the medical institution, the technique of the operation and the quality of the postoperative management of the patient. In different clinics, the risks differ significantly.This is the main reason why people travel to Germany for surgery. Indeed, in German clinics, the risk of complications and mortality of patients is much lower.
Late complications are also possible, significantly impairing the patient’s quality of life. The statistics of their occurrence differ significantly, depending on where and how the person was treated. The risk of complications can range from 6 to 24% in different clinics. The main ones are:
- Dysfunction of the sphincter of Oddi
- Duodeno-biliary reflux (entry of the contents of the small intestine into the bile ducts)
- Chronic cholangitis
- Recurrence of cholelithiasis (reappearance of stones)
In Germany, not dissection, but expansion is often used (dilation) of the sphincter when accessing the bile ducts.This type of intervention is more preferable. It carries fewer risks of long-term complications. After such an operation, the functional state of the sphincter apparatus is always preserved. The method can be used even with large stones, but in this case, lithotripsy (crushing) is required, followed by the extraction of stones in parts.
Organization of treatment
If you need to remove stones from the bile ducts, you can go to one of the clinics in Germany. You do not have to look for a clinic on your own, negotiate with the administration, establish communication with doctors, look for translators and solve a lot of organizational issues.Booking Health can do all this for you.
We organize treatment for you in the best clinics in Germany. Our services:
- Choosing a clinic that specializes in minimally invasive operations for the removal of gallstones and demonstrates the best results according to medical statistics.
- The treatment program is planned taking into account your diagnosis and concomitant diseases. We will translate the available research data into German, so you do not have to undergo the examination again.
- Diagnostics and treatment will take place on the dates that you find convenient, and the waiting time for the operation will be reduced.
- Treatment in Germany will cost significantly less due to the absence of allowances for foreign patients – the cost of treatment will be reduced by up to 50%.
- We will provide control of the program at all its stages, as well as control over the expenditure of your funds. Anything not spent will be returned to your bank account after the end of the program.
- Assistance in sending medicines abroad.
Booking Health provides a high level of service. We will help you prepare documents, book flights and a hotel for you, provide an interpreter and support you throughout your stay in Germany.
Choose treatment abroad and you will undoubtedly get an excellent result!
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Authors: Dr. Nadezhda Ivanisova, Dr. Sergey Pashchenko
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The gallbladder is not considered a vital organ, but if stones are found in it, it becomes a threat to both health and life.It is necessary to take care of getting rid of this problem as soon as possible, without waiting for hepatic colic or other complications, advises the deputy chief physician for surgery at the CMT clinics, Ph.D. Sergey Basos.
– Sergey Fedorovich, removal of the gallbladder (cholicetectomy) is considered the most common operation in the world. Why does it have to be removed so often?
– Because, unfortunately, there is no other way to save a person from cholelithiasis (GSD) and its very dangerous complications.
– How is gallstone disease manifested?
– Dyspeptic symptoms may indicate the formation of stones in the gallbladder – nausea, belching, heartburn, provoked by impaired digestion of food in the gastrointestinal tract, bile entering the stomach and esophagus. Often, gallstones is manifested by aching pains in the right hypochondrium 30-40 minutes after eating. The severity of these pains can be different – from an unpleasant feeling of heaviness to a pronounced pain syndrome with irradiation into the right shoulder girdle under the right shoulder blade, which leads to disruption of human activity and requires medical intervention.Moreover, sometimes pain is easily relieved by the appointment of antispasmodics and a state of rest, and sometimes lead to hospitalization. Hepatic colic is a very dangerous manifestation of the disease, in some cases it ends with the development of acute cholecystitis associated with the wedging of a gallbladder stone and the onset of an infectious process. In this case, emergency surgery is performed.
In the photo: Basos S.F. and Sheiko S.B., Laparoscopic cholecystectomy, “Surgical complex SMT” pr. Rimsky-Korsakov, 87
– And if stones in the gallbladder have become a so-called accidental finding on ultrasound, is it worth doing an operation?
– There is such a form of the disease – asymptomatic cholecystolithiasis. With her, there are stones in the gallbladder, but there are no clinical manifestations of the disease: for the time being, the human condition is not overshadowed by anything.But the presence of stones in the gallbladder in this complex anatomical and functional area sooner or later leads to dysfunctions of the surrounding organs. It can provoke the formation of ulcers of the duodenum and stomach, maintain chronic gastritis, and can lead to the gradual formation of chronic pancreatitis. And if a person carries stones in himself for a long time, the risk of developing diabetes mellitus increases by an order of magnitude. The likelihood of gallbladder cancer is not excluded.
– Can a person treat gastritis provoked by gallstone disease all his life without finding the true cause?
– EGD and abdominal ultrasound put everything in its place almost without a doubt.These studies are required when pain occurs in the right hypochondrium.
– What is the relationship between pancreatitis, diabetes mellitus and gallstone disease?
– The organs located in the abdominal cavity are closely interconnected. The fact is that the common bile duct, into which the gallbladder duct opens, goes directly from the liver to the duodenum, in the same place it goes into the duodenum and pancreatic duct. The presence of pain symptoms leads to discoordination of the sphincter to spasm, and spasm – to an increase in pressure in the ducts, damage to pancreatic cells, scar tissue appears, which eventually leads to a decrease in the number of cells that produce enzymes for digesting food, as well as cells that produce hormones – insulin responsible for carbohydrate metabolism.Thus, chronic pancreatitis and diabetes mellitus are often caused by the gastrointestinal tract.
In the photo: Basos S.F. and Sheiko S.B., Choledocholithotomy choledocholithotomy by laparotomy access, “Surgical complex SMT” pr. Rimsky-Korsakov, 87
– Can this condition be confused with osteochondrosis: a person has gallstone disease, and he is diagnosed with osteochondrosis with intercostal neuralgia?
– More often, with such symptoms, they still first of all think about gallstone disease than about neuralgia.But sometimes, indeed, the clinic of gallstone disease can be simulated by a banal intercostal neuralgia at the level of 5-6-7 ribs. The pain radiates along the intercostal spaces and is localized in the right hypochondrium, which can be mistakenly interpreted as an exacerbation of gallstone disease. Palpation examination of the intercostal spaces allows you to find a pain point and confidently conclude that the cause of the pain syndrome in this case is neuralgia.
– Who is at high risk of gallstones? What provokes this process?
– Women most often suffer – 6-8 times more often than men.This is due to both the physiology of the female body and pregnancy, the metabolism changes, and in the later stages, when the uterus increases in size and pushes the internal organs, the emptying of the gallbladder worsens and conditions are created in it for the crystallization of cholesterol and the formation of stones.
There are other predisposing factors that are characteristic of both men and women. This is heredity, features of metabolism or the structure of the biliary tract, in which conditions arise for incomplete emptying of the gallbladder and the formation of crystals of bile acids and cholesterol with the formation of gallstones.In addition, obesity is recognized as a risk factor for the development of gallstone disease.
– Does this mean that reducing fatty and high-calorie foods in the diet can prevent the formation of gallstones?
– The formation of stones is facilitated by a biochemical violation of the ratio of fatty acids and lecithin, which is in the composition of bile. Perhaps this violation occurs due to an excess of fatty foods. But it is impossible to completely abandon fats, because they cause an increased contraction of the gallbladder and its emptying, preventing the phenomenon of stagnation.
Prevention of gallstone disease is a healthy, active lifestyle, and a diet with a predominance of foods containing plant fiber. Fatty foods are still in limited quantities.
In the photo: Sergey Fedorovich Basos, surgeon of the highest category, candidate of medical sciences, head.surgery “Clinic CMT”
– Patients are trying to cure gallstones with therapeutic methods, such as drugs to dissolve stones.
– Gastroenterologists conduct an examination and, according to indications, prescribe a diet restricting spicy, fatty, fried foods, stone-dissolving therapy, the use of antispasmodic drugs to reduce stagnation in the biliary tract. But this treatment is very rarely effective.In order for the stones to dissolve with such treatment, they must be single, small in size, and the gallbladder must have a good contractile function. If the gallbladder does not contract, then the effect of litholytic (stone-dissolving) drugs is ineffective.
– What research needs to be done to understand whether drug therapy will help or should you go straight to the surgeon?
– To find out whether stone-dissolving therapy will be effective, gastroenterologists prescribe a computed tomography, which reveals the structure, density, size of stones, contraction of the gallbladder after taking a choleretic breakfast.Without taking into account these data, it is pointless to carry out litoroluble therapy. In any case, while the main method of treatment has been and remains the operative method.
– However, surgeons often say that the best surgery is the one that isn’t done.
– Yes, there is an opinion even in enlightened Petersburg that there is nothing superfluous in the body and if there is an opportunity to do without surgery, then it is better not to do it. This tactic leads to the fact that at least 40% of surgical interventions are carried out for emergency indications – patients develop acute cholecystitis or other complications of cholelithiasis requiring surgical intervention.But against the background of developed anatomical changes, inflammatory processes in the gallbladder and bile ducts, it is more traumatic, it has more risks of developing intraoperative complications (damage to nearby structures) and more difficult recovery. Planned intervention is much easier to tolerate, after which the person is safely recovered. In addition, the age at which this occurs is also important. It is one thing to operate on a young person, whose recovery is fast, and another thing – on an elderly person with a number of concomitant diseases (coronary artery disease, hypertension).He needs to be prepared for surgery, otherwise, if operated on an emergency basis, the risk of an unfavorable outcome increases.
– You can understand a person who does not want to lie under the surgeon’s scalpel on the operating table …
– Laparotomy is a traumatic abdominal operation, fraught with serious complications, has long been in the past. With the advent of endovideosurgery, operations with extensive trauma on the anterior abdominal wall disappeared. Nowadays laparoscopic treatment of gallstone disease is called the gold standard.Our clinic offers the widest range of laparoscopic operations in the city.
Traditionally, they are made through 4 punctures and drainage is left in the early postoperative period. And we switched to the technology of three punctures – this reduces the pain syndrome and in the overwhelming majority of cases does not require drainage.
Often in patients, gallstone disease is combined with a developing umbilical hernia. In this case, we make an incision in the navel area (along the lower semicircle), all instruments are installed in the area of this incision, cholecystectomy is performed – the gallbladder is removed through the same opening and at the end of the operation the umbilical hernia is removed.As a result, a small scar remains under the navel.
There are women who do not want to have even small scars in the abdomen after laparoscopic surgery. Then operations are performed using N.O.T.E.S. technology. through natural openings – the instruments are installed deep in the navel so that no one can subsequently detect the scar, and the actual operation is performed through the posterior fornix of the vagina (there are no pain receptors in this area), through which the gallbladder is also removed. Everything is sutured with an atraumatic absorbable suture so that the stitches do not need to be removed and there are no scars after the operation.
This technology is widely used in the world. It differs from other operations in that the patient has less pronounced postoperative pain syndrome, the rehabilitation period is shorter and, accordingly, the person returns to an active life faster. In Russia, it is used in several medical centers, but our clinic has the richest experience. It is popular with young women who have stones that have triggered pregnancy and childbirth. And after this operation, they give birth again without any problems – this surgical intervention has no effect on reproductive function.
In our clinic, we practice simultaneous operations for several diseases in different anatomical areas. For example, a combination of an ovarian cyst and gallstone disease. This approach allows you to simultaneously solve several problems with one anesthesia and one recovery period.
Stones in the gallbladder – medical center “YOUR DOCTOR” Mine
Gallstone disease is a pathology of the body in which stones are found in the gallbladder and its ducts.Their formation is explained by the sediment of various components of bile. With stagnation of bile, a disturbed metabolism is observed, which can lead to infection. On the right side, under the ribs, aching pains appear, which are considered the main signs of gallstone disease. In this case, it does not hurt to make an appointment with the surgeon in order to make the correct diagnosis.
Added to them is a slight jaundice of the skin. Among the many reasons that cause cholelithiasis, there are inactivity, prolonged fasting, pregnancy, various injuries, liver pathologies.The clinic of the disease can be very different. It depends on the location of the stones and their size.
Usually it is increased weakness, frequent ailments, fever. May be disturbed by flatulence, heartburn, indigestion. Hepatic colic has an acute character of pain, can be felt in the back and right shoulder blade. It can also disturb the heart. The pain increases after eating spicy or fatty foods. Alcohol consumption, exercise, or stress can trigger an attack.
The patient may complain of fever and fecal discoloration.If you do not seek medical help, the situation can be complicated by calculous cholecystitis. Because of this, appetite may sharply decrease and increased fatigue may appear. If stones are found in the gallbladder, doctors advise to take a wait-and-see tactic.
If the patient is not worried about anything, and there is no danger of complications, then it is not worth removing the gallbladder yet. Sometimes conservative treatment will be sufficient. This is the reception of medicines, herbal infusions. In addition to medications, the doctor will advise you to follow a special diet.It consists in eating small meals, limiting spicy and fatty foods, avoiding fried and cholesterol-rich foods.
Fresh vegetables and fruits, greens must be present in the diet. With an exacerbation of the situation and poor health of the patient, surgical treatment is indicated. The operation of cholecystectomy is performed in a hospital, in the surgical department. It is prescribed to patients with exacerbations of hepatic colic, with large stones, in the presence of an elevated temperature.The method of conducting the operation is developed individually.