Gallstones (Cholelithiasis) – StatPearls – NCBI Bookshelf

Mark W. Jones; Connor B. Weir; Sassan Ghassemzadeh.

Author Information and Affiliations

Last Update: April 24, 2023.

Continuing Education Activity

Gallstones or cholelithiasis are stones that form in the gallbladder composed of cholesterol, bilirubin, and bile. These stones are asymptomatic in most cases, with stones discovered incidentally. Symptomatic patients present with right upper abdominal pain after eating greasy or spicy food, nausea, vomiting, pain in epigastrium that radiates to the right scapula or mid-back. This activity illustrates the evaluation and management of gallstones and reviews the role of the interprofessional team in improving care for patients with this condition.

Objectives:

• Identify the risk factors associated with the development of gallstones.

• Describe the pathophysiology of gallstones.

• Outline the use of a right upper quadrant abdominal ultrasound in the evaluation of gallstones.

• Explain the importance of improving care coordination among the interprofessional team members to improve outcomes for patients affected by gallstones.

Access free multiple choice questions on this topic.

Introduction

Gallstones or cholelithiasis are responsible for one of the most prevalent digestive disorders in the United States. They are considered a disease of developed populations but are present around the world. It is both the result of a chronic disease process and the cause of subsequent acute disorders of the pancreatic, biliary, hepatic, and gastrointestinal tract. Over 6.3 million females and 14.2 million males in the United States between the ages of 20 and 74 have gallstones. Most patients with gallstones are asymptomatic, but 10% of patients will develop symptoms within five years, and 20% of patients will develop symptoms within 20 years of diagnosing gallstones. Gallstone prevalence also increases with age. Over one-quarter of females older than the age of 60 will have gallstones. Gallstones have various compositions and etiologies.[1]

The critical feature of gallstones is that they are not all symptomatic. Sometimes they may migrate near the opening of the cystic duct and block the flow of bile. This can lead to tension in the gallbladder, which results in the classic biliary colicky pain. If the cystic duct is obstructed for more than a few hours, it can lead to inflammation of the gallbladder wall (cholecystitis). Sometimes the gallstone may move into the bile duct and cause obstruction, leading to jaundice and abdominal pain. Patients who have chronic gallstones may develop progressive fibrosis and loss of motor function of the gallbladder. The best test to make a diagnosis of gallstones is ultrasound. The treatment of gallstones depends on symptoms. The standard of care for symptomatic patients is laparoscopic cholecystectomy.

Etiology

Gallstones usually form from sluggishly emptying of bile from the gallbladder. When bile is not fully drained from the gallbladder, it can precipitate as sludge, which in turn can develop into gallstones. Biliary obstruction from various causes such as strictures in the bile duct or neoplasms may also lead to gallstones. The most common cause of cholelithiasis is the precipitation of cholesterol from cholesterol-rich bile. The second most common form of gallstones is pigmented gallstones. These form from the breakdown of red blood cells and are black. The third type of gallstones is mixed pigmented stones, a combination of calcium substrates such as calcium carbonate or calcium phosphate, cholesterol, and bile. The fourth type of stone is calcium stones. These may be due to the precipitation of serum calcium in patients with hypercalcemia. Often these patients will have concurrent kidney stones.[2]

Risk factors for gallstones include:

• In pregnancy, progesterone decreases the contractility of the gallbladder leading to stasis.

• Obesity

• Genes

• Certain medications (estrogens, fibrates, somatostatin analogs)

• Stasis of the gallbladder

• Female gender

• Metabolic syndrome

• Rapid weight loss

• Prolonged fasting

• Bariatric surgery

• Crohn disease, ileal resection

Epidemiology

Most gallstones are asymptomatic. In the United States, approximately 14 million women and 6 million men with an age range of 20 to 74 have gallstones. The prevalence increases as a person ages. Obesity increases the likelihood of gallstones, especially in women, due to increases in the biliary secretion of cholesterol. On the other hand, patients with drastic weight loss or fasting have a higher chance of gallstones secondary to biliary stasis. Furthermore, there is also a hormonal association with gallstones. Estrogen has been shown to result in an increase in bile cholesterol as well as a decrease in gallbladder contractility. Women of reproductive age or on estrogen-containing birth control medication have a two-fold increase in gallstone formation compared to males. People with chronic illnesses such as diabetes also have an increase in gallstone formation and reduced gallbladder wall contractility due to neuropathy.[3]

Pathophysiology

Gallstones occur when substances in the bile reach their limits of solubility. As bile becomes concentrated in the gallbladder, it becomes supersaturated with these substances, which in time precipitate into small crystals. These crystals, in turn, become stuck in the gallbladder mucus, resulting in gallbladder sludge. Over time, these crystals grow and form large stones. Complications caused by gallstones are a direct consequence of occlusion of the hepatic and biliary tree by sludge and stones.[3]

There are two types of gallstones, cholesterol and calcium bilirubinate.

Cholesterol gallstones form the majority of gallstones. The major component of these stones is cholesterol. The bilirubinate stones contain bilirubin. In patients with a high turnover of heme, such as cirrhosis or chronic hemolysis, the unconjugated bilirubin will crystallize and eventually form stones. These stones are usually dark black or blue and account for about 15% of gallstones in the United States.

Sometimes, the cholesterol gallstones will become colonized with microorganisms, which leads to inflammation of the mucosa. The resulting leucocyte infiltration and presence of bilirubin leads to mixed stones.

Histopathology

Pathologists can analyze the composition of gallstones and bile, which may help to determine the cause of the stones, especially in cases of primary common bile duct stones, after gallbladder removal and the exact cause of the stones is unknown.[4][5]

History and Physical

Usually, patients with symptoms from gallstones present with right upper abdominal pain after eating greasy or spicy foods. There is often nausea and vomiting. Pain can also be present in the epigastric area that radiates to the right scapula or mid-back. The classic physical exam finding is a positive Murphy’s sign, where the pain is elicited on deep palpation to the right upper quadrant underneath the rib cage upon deep inspiration. Patients may be asymptomatic for months to years until the discovery of gallstones. Acute cholecystitis presents similarly. However, it is more severe. Jaundice can be a sign of a common bile duct obstruction from an entrapped gallstone.  In the presence of jaundice and abdominal pain, often, a procedure is an indication to go and retrieve the stone to prevent further sequelae. One such sequela is ascending cholangitis, with symptoms of right upper abdominal pain, fever, and jaundice (Charcot’s triad). Progression of this condition is indicated by neurologic changes and hypotension (Reynold’s pentad). Other sequelae are acute pancreatitis with symptoms of mid-epigastric pain and intractable vomiting.[6]

Evaluation

The best diagnostic test for diagnosing gallstones and subsequent acute cholecystitis is a right upper quadrant abdominal ultrasound. It is associated with a 90% specificity rate and, depending on the ultrasound operator, can detect stones as small as 2 mm as well as sludge and gallbladder polyps. Ultrasound findings that point towards acute cholecystitis versus cholelithiasis include gallbladder wall thickening greater than 3 mm, pericholecystic fluid, and a positive sonographic Murphy’s sign. Gallstones can also often be present on CT scans and MRIs. However, these tests are not as sensitive for diagnosing acute cholecystitis. Approximately 10% of gallstones may be found on routine plain films due to their high calcium content. If there is a suspected stone in the common bile duct based on ultrasound results, magnetic resonance cholangiopancreatography (MRCP) is the next step. If a common duct stone is identified on the MRCP, then the gold-standard test of an endoscopic retrograde cholangiopancreatogram (ERCP) should be performed by a gastroenterologist. A percutaneous transhepatic cholangiogram (PTHC) is also useful in diagnosing common bile duct stones if an ERCP is not possible.[7]

Treatment / Management

Cholecystectomy treats symptomatic gallstones. The laparoscopic approach is the standard of care. Open cholecystectomies are the option when it is not practical or advisable to do a laparoscopic procedure. It is not wise to only remove the gallstones as studies have shown that they recur after about one year. In cases of acute cholecystitis in critically ill patients or patients who are poor surgical candidates, a decompression cholecystostomy tube can be placed to temporize the patient until stable enough for definitive surgery. Common bile duct stones can be removed with a preoperative or postoperative ERCP, PTHC, or operatively with a common bile duct exploration. Ascending cholangitis needs to be addressed urgently by removing the blockage either with ERCP, PTHC, or surgery, as well as early antibiotic administration. In cases of nonacute cholecystitis and very poor surgical candidates, gallstones can be treated medically. Ursodiol is administered daily with the hope of dissolving the gallstones and has shown mixed success with some studies at best, showing less than a 50% response rate.[8]

Differential Diagnosis

Prognosis

Less than 50% of patients who have gallstones will develop symptoms. Today, the mortality rate following laparoscopic cholecystectomy is less than 1%; however, emergency cholecystectomy rates are 10% or greater. Other complications include retained stones in the bile duct, incisional hernia, and chronic right upper quadrant pain. Despite the fact that laparoscopic cholecystectomy is now the standard of care for symptomatic gallstones, the rates of injury to the bile duct during surgery continue to increase.

Complications

Complications from gallstones may include [9][10]:

• Gallbladder inflammation leading to cholecystitis

• Common bile duct blockage resulting in bile duct infection and jaundice

• Pancreatic duct blockage which can cause pancreatitis

• Cancer of the gallbladder

Deterrence and Patient Education

Patient education centers around maintaining a low-fat diet, medication adherence, explaining the pathophysiology of the condition, follow-up appointments to track progress, and explaining potential surgical interventions if they become necessary.

Enhancing Healthcare Team Outcomes

Gallbladder disease can be a difficult diagnosis. Early suspicion with proper testing will make the diagnosis. The condition is best managed by an interprofessional team. Having a skilled radiologist and emergency physician will often be the critical first step in properly diagnosing gallstones. Early intervention by an experienced surgeon is also vital. Practitioners should remember that not all gallstones will require surgery. The correct clinical decision must be made as a group recommendation between the primary care physician, nurse practitioner, radiologist, gastroenterologist, the patient, and the surgeon. The primary care clinicians should encourage patients to eat a healthy diet, maintain healthy body weight, eat a low-fat diet, and abstain from prolonged fasting. Nurses monitor patients perioperatively, educate patients and their families, and inform the team of changes in patient status. Close communication between the team members if vital to lower the morbidity of gallstones.[11][12][13]

Review Questions

• Access free multiple choice questions on this topic.

• Comment on this article.

Figure

Gallstone on point-of-care ultrasound. Contributed by Emory EM Ultrasound Section

Figure

CT Acute Cholecystitis Wall Thickening Pericholecystic Fluid Gallstone. Contributed by Scott Dulebohn, MD

Figure

Gallstones in a female. Image courtesy S Bhimji

Figure

Figure 1. 37-year old female diagnosed as gallstones with acute cholecystitis. The incidental findings ; a: US image show multiple hypoechoic lesions, some of them with comet-tail artifacts, raises the possibility of multiple biliary hamartoma; b: T2-weighted (more…)

Figure

Gallbladder Gallstones (Calculi), Common
bile duct, Pancreas, Intestine, Gallbladder, Gallstones, Liver. Illustration by Emma Gregory

References

1.

Tsai TJ, Chan HH, Lai KH, Shih CA, Kao SS, Sun WC, Wang EM, Tsai WL, Lin KH, Yu HC, Chen WC, Wang HM, Tsay FW, Lin HS, Cheng JS, Hsu PI. Gallbladder function predicts subsequent biliary complications in patients with common bile duct stones after endoscopic treatment? BMC Gastroenterol. 2018 Feb 27;18(1):32. [PMC free article: PMC6389262] [PubMed: 29486713]

2.

Rebholz C, Krawczyk M, Lammert F. Genetics of gallstone disease. Eur J Clin Invest. 2018 Jul;48(7):e12935. [PubMed: 29635711]

3.

Shabanzadeh DM. New determinants for gallstone disease?
. Dan Med J. 2018 Feb;65(2) [PubMed: 29393043]

4.

Del Pozo R, Mardones L, Villagrán M, Muñoz K, Roa S, Rozas F, Ormazábal V, Muñoz M. [Effect of a high-fat diet on cholesterol gallstone formation]. Rev Med Chil. 2017 Sep;145(9):1099-1105. [PubMed: 29424395]

5.

Charfi S, Gouiaa N, Mnif H, Chtourou L, Tahri N, Abid B, Mzali R, Boudawara TS. Histopathological findings in cholecystectomies specimens: A single institution study of 20 584 cases. Hepatobiliary Pancreat Dis Int. 2018 Aug;17(4):345-348. [PubMed: 30173787]

6.

Wilkins T, Agabin E, Varghese J, Talukder A. Gallbladder Dysfunction: Cholecystitis, Choledocholithiasis, Cholangitis, and Biliary Dyskinesia. Prim Care. 2017 Dec;44(4):575-597. [PubMed: 29132521]

7.

Hiwatashi K, Okumura H, Setoyama T, Ando K, Ogura Y, Aridome K, Maenohara S, Natsugoe S. Evaluation of laparoscopic cholecystectomy using indocyanine green cholangiography including cholecystitis: A retrospective study. Medicine (Baltimore). 2018 Jul;97(30):e11654. [PMC free article: PMC6078678] [PubMed: 30045318]

8.

Hirajima S, Koh T, Sakai T, Imamura T, Kato S, Nishimura Y, Soga K, Nishio M, Oguro A, Nakagawa N. Utility of Laparoscopic Subtotal Cholecystectomy with or without Cystic Duct Ligation for Severe Cholecystitis. Am Surg. 2017 Nov 01;83(11):1209-1213. [PubMed: 29183521]

9.

Del Vecchio Blanco G, Gesuale C, Varanese M, Monteleone G, Paoluzi OA. Idiopathic acute pancreatitis: a review on etiology and diagnostic work-up. Clin J Gastroenterol. 2019 Dec;12(6):511-524. [PubMed: 31041651]

10.

Brägelmann J, Barahona Ponce C, Marcelain K, Roessler S, Goeppert B, Gallegos I, Colombo A, Sanhueza V, Morales E, Rivera MT, de Toro G, Ortega A, Müller B, Gabler F, Scherer D, Waldenberger M, Reischl E, Boekstegers F, Garate-Calderon V, Umu SU, Rounge TB, Popanda O, Lorenzo Bermejo J. Epigenome-Wide Analysis of Methylation Changes in the Sequence of Gallstone Disease, Dysplasia, and Gallbladder Cancer. Hepatology. 2021 Jun;73(6):2293-2310. [PubMed: 33020926]

11.

Patel SS, Kohli DR, Savas J, Mutha PR, Zfass A, Shah TU. Surgery Reduces Risk of Complications Even in High-Risk Veterans After Endoscopic Therapy for Biliary Stone Disease. Dig Dis Sci. 2018 Mar;63(3):781-786. [PubMed: 29380173]

12.

Genser L, Vons C. Can abdominal surgical emergencies be treated in an ambulatory setting? J Visc Surg. 2015 Dec;152(6 Suppl):S81-9. [PubMed: 26522504]

13.

Coleman J. Bile duct injuries in laparoscopic cholecystectomy: nursing perspective. AACN Clin Issues. 1999 Nov;10(4):442-54. [PubMed: 10865529]

Disclosure: Mark Jones declares no relevant financial relationships with ineligible companies.

Disclosure: Connor Weir declares no relevant financial relationships with ineligible companies.

Disclosure: Sassan Ghassemzadeh declares no relevant financial relationships with ineligible companies.

Gallstones (Cholelithiasis) – StatPearls – NCBI Bookshelf

Mark W. Jones; Connor B. Weir; Sassan Ghassemzadeh.

Author Information and Affiliations

Last Update: April 24, 2023.

Continuing Education Activity

Gallstones or cholelithiasis are stones that form in the gallbladder composed of cholesterol, bilirubin, and bile. These stones are asymptomatic in most cases, with stones discovered incidentally. Symptomatic patients present with right upper abdominal pain after eating greasy or spicy food, nausea, vomiting, pain in epigastrium that radiates to the right scapula or mid-back. This activity illustrates the evaluation and management of gallstones and reviews the role of the interprofessional team in improving care for patients with this condition.

Objectives:

• Identify the risk factors associated with the development of gallstones.

• Describe the pathophysiology of gallstones.

• Outline the use of a right upper quadrant abdominal ultrasound in the evaluation of gallstones.

• Explain the importance of improving care coordination among the interprofessional team members to improve outcomes for patients affected by gallstones.

Access free multiple choice questions on this topic.

Introduction

Gallstones or cholelithiasis are responsible for one of the most prevalent digestive disorders in the United States. They are considered a disease of developed populations but are present around the world. It is both the result of a chronic disease process and the cause of subsequent acute disorders of the pancreatic, biliary, hepatic, and gastrointestinal tract. Over 6.3 million females and 14.2 million males in the United States between the ages of 20 and 74 have gallstones. Most patients with gallstones are asymptomatic, but 10% of patients will develop symptoms within five years, and 20% of patients will develop symptoms within 20 years of diagnosing gallstones. Gallstone prevalence also increases with age. Over one-quarter of females older than the age of 60 will have gallstones. Gallstones have various compositions and etiologies.[1]

The critical feature of gallstones is that they are not all symptomatic. Sometimes they may migrate near the opening of the cystic duct and block the flow of bile. This can lead to tension in the gallbladder, which results in the classic biliary colicky pain. If the cystic duct is obstructed for more than a few hours, it can lead to inflammation of the gallbladder wall (cholecystitis). Sometimes the gallstone may move into the bile duct and cause obstruction, leading to jaundice and abdominal pain. Patients who have chronic gallstones may develop progressive fibrosis and loss of motor function of the gallbladder. The best test to make a diagnosis of gallstones is ultrasound. The treatment of gallstones depends on symptoms. The standard of care for symptomatic patients is laparoscopic cholecystectomy.

Etiology

Gallstones usually form from sluggishly emptying of bile from the gallbladder. When bile is not fully drained from the gallbladder, it can precipitate as sludge, which in turn can develop into gallstones. Biliary obstruction from various causes such as strictures in the bile duct or neoplasms may also lead to gallstones. The most common cause of cholelithiasis is the precipitation of cholesterol from cholesterol-rich bile. The second most common form of gallstones is pigmented gallstones. These form from the breakdown of red blood cells and are black. The third type of gallstones is mixed pigmented stones, a combination of calcium substrates such as calcium carbonate or calcium phosphate, cholesterol, and bile. The fourth type of stone is calcium stones. These may be due to the precipitation of serum calcium in patients with hypercalcemia. Often these patients will have concurrent kidney stones.[2]

Risk factors for gallstones include:

• In pregnancy, progesterone decreases the contractility of the gallbladder leading to stasis.

• Obesity

• Genes

• Certain medications (estrogens, fibrates, somatostatin analogs)

• Stasis of the gallbladder

• Female gender

• Metabolic syndrome

• Rapid weight loss

• Prolonged fasting

• Bariatric surgery

• Crohn disease, ileal resection

Epidemiology

Most gallstones are asymptomatic. In the United States, approximately 14 million women and 6 million men with an age range of 20 to 74 have gallstones. The prevalence increases as a person ages. Obesity increases the likelihood of gallstones, especially in women, due to increases in the biliary secretion of cholesterol. On the other hand, patients with drastic weight loss or fasting have a higher chance of gallstones secondary to biliary stasis. Furthermore, there is also a hormonal association with gallstones. Estrogen has been shown to result in an increase in bile cholesterol as well as a decrease in gallbladder contractility. Women of reproductive age or on estrogen-containing birth control medication have a two-fold increase in gallstone formation compared to males. People with chronic illnesses such as diabetes also have an increase in gallstone formation and reduced gallbladder wall contractility due to neuropathy.[3]

Pathophysiology

Gallstones occur when substances in the bile reach their limits of solubility. As bile becomes concentrated in the gallbladder, it becomes supersaturated with these substances, which in time precipitate into small crystals. These crystals, in turn, become stuck in the gallbladder mucus, resulting in gallbladder sludge. Over time, these crystals grow and form large stones. Complications caused by gallstones are a direct consequence of occlusion of the hepatic and biliary tree by sludge and stones.[3]

There are two types of gallstones, cholesterol and calcium bilirubinate.

Cholesterol gallstones form the majority of gallstones. The major component of these stones is cholesterol. The bilirubinate stones contain bilirubin. In patients with a high turnover of heme, such as cirrhosis or chronic hemolysis, the unconjugated bilirubin will crystallize and eventually form stones. These stones are usually dark black or blue and account for about 15% of gallstones in the United States.

Sometimes, the cholesterol gallstones will become colonized with microorganisms, which leads to inflammation of the mucosa. The resulting leucocyte infiltration and presence of bilirubin leads to mixed stones.

Histopathology

Pathologists can analyze the composition of gallstones and bile, which may help to determine the cause of the stones, especially in cases of primary common bile duct stones, after gallbladder removal and the exact cause of the stones is unknown.[4][5]

History and Physical

Usually, patients with symptoms from gallstones present with right upper abdominal pain after eating greasy or spicy foods. There is often nausea and vomiting. Pain can also be present in the epigastric area that radiates to the right scapula or mid-back. The classic physical exam finding is a positive Murphy’s sign, where the pain is elicited on deep palpation to the right upper quadrant underneath the rib cage upon deep inspiration. Patients may be asymptomatic for months to years until the discovery of gallstones. Acute cholecystitis presents similarly. However, it is more severe. Jaundice can be a sign of a common bile duct obstruction from an entrapped gallstone.  In the presence of jaundice and abdominal pain, often, a procedure is an indication to go and retrieve the stone to prevent further sequelae. One such sequela is ascending cholangitis, with symptoms of right upper abdominal pain, fever, and jaundice (Charcot’s triad). Progression of this condition is indicated by neurologic changes and hypotension (Reynold’s pentad). Other sequelae are acute pancreatitis with symptoms of mid-epigastric pain and intractable vomiting.[6]

Evaluation

The best diagnostic test for diagnosing gallstones and subsequent acute cholecystitis is a right upper quadrant abdominal ultrasound. It is associated with a 90% specificity rate and, depending on the ultrasound operator, can detect stones as small as 2 mm as well as sludge and gallbladder polyps. Ultrasound findings that point towards acute cholecystitis versus cholelithiasis include gallbladder wall thickening greater than 3 mm, pericholecystic fluid, and a positive sonographic Murphy’s sign. Gallstones can also often be present on CT scans and MRIs. However, these tests are not as sensitive for diagnosing acute cholecystitis. Approximately 10% of gallstones may be found on routine plain films due to their high calcium content. If there is a suspected stone in the common bile duct based on ultrasound results, magnetic resonance cholangiopancreatography (MRCP) is the next step. If a common duct stone is identified on the MRCP, then the gold-standard test of an endoscopic retrograde cholangiopancreatogram (ERCP) should be performed by a gastroenterologist. A percutaneous transhepatic cholangiogram (PTHC) is also useful in diagnosing common bile duct stones if an ERCP is not possible.[7]

Treatment / Management

Cholecystectomy treats symptomatic gallstones. The laparoscopic approach is the standard of care. Open cholecystectomies are the option when it is not practical or advisable to do a laparoscopic procedure. It is not wise to only remove the gallstones as studies have shown that they recur after about one year. In cases of acute cholecystitis in critically ill patients or patients who are poor surgical candidates, a decompression cholecystostomy tube can be placed to temporize the patient until stable enough for definitive surgery. Common bile duct stones can be removed with a preoperative or postoperative ERCP, PTHC, or operatively with a common bile duct exploration. Ascending cholangitis needs to be addressed urgently by removing the blockage either with ERCP, PTHC, or surgery, as well as early antibiotic administration. In cases of nonacute cholecystitis and very poor surgical candidates, gallstones can be treated medically. Ursodiol is administered daily with the hope of dissolving the gallstones and has shown mixed success with some studies at best, showing less than a 50% response rate.[8]

Differential Diagnosis

Prognosis

Less than 50% of patients who have gallstones will develop symptoms. Today, the mortality rate following laparoscopic cholecystectomy is less than 1%; however, emergency cholecystectomy rates are 10% or greater. Other complications include retained stones in the bile duct, incisional hernia, and chronic right upper quadrant pain. Despite the fact that laparoscopic cholecystectomy is now the standard of care for symptomatic gallstones, the rates of injury to the bile duct during surgery continue to increase.

Complications

Complications from gallstones may include [9][10]:

• Gallbladder inflammation leading to cholecystitis

• Common bile duct blockage resulting in bile duct infection and jaundice

• Pancreatic duct blockage which can cause pancreatitis

• Cancer of the gallbladder

Deterrence and Patient Education

Patient education centers around maintaining a low-fat diet, medication adherence, explaining the pathophysiology of the condition, follow-up appointments to track progress, and explaining potential surgical interventions if they become necessary.

Enhancing Healthcare Team Outcomes

Gallbladder disease can be a difficult diagnosis. Early suspicion with proper testing will make the diagnosis. The condition is best managed by an interprofessional team. Having a skilled radiologist and emergency physician will often be the critical first step in properly diagnosing gallstones. Early intervention by an experienced surgeon is also vital. Practitioners should remember that not all gallstones will require surgery. The correct clinical decision must be made as a group recommendation between the primary care physician, nurse practitioner, radiologist, gastroenterologist, the patient, and the surgeon. The primary care clinicians should encourage patients to eat a healthy diet, maintain healthy body weight, eat a low-fat diet, and abstain from prolonged fasting. Nurses monitor patients perioperatively, educate patients and their families, and inform the team of changes in patient status. Close communication between the team members if vital to lower the morbidity of gallstones.[11][12][13]

Review Questions

• Access free multiple choice questions on this topic.

• Comment on this article.

Figure

Gallstone on point-of-care ultrasound. Contributed by Emory EM Ultrasound Section

Figure

CT Acute Cholecystitis Wall Thickening Pericholecystic Fluid Gallstone. Contributed by Scott Dulebohn, MD

Figure

Gallstones in a female. Image courtesy S Bhimji

Figure

Figure 1. 37-year old female diagnosed as gallstones with acute cholecystitis. The incidental findings ; a: US image show multiple hypoechoic lesions, some of them with comet-tail artifacts, raises the possibility of multiple biliary hamartoma; b: T2-weighted (more…)

Figure

Gallbladder Gallstones (Calculi), Common
bile duct, Pancreas, Intestine, Gallbladder, Gallstones, Liver. Illustration by Emma Gregory

References

1.

Tsai TJ, Chan HH, Lai KH, Shih CA, Kao SS, Sun WC, Wang EM, Tsai WL, Lin KH, Yu HC, Chen WC, Wang HM, Tsay FW, Lin HS, Cheng JS, Hsu PI. Gallbladder function predicts subsequent biliary complications in patients with common bile duct stones after endoscopic treatment? BMC Gastroenterol. 2018 Feb 27;18(1):32. [PMC free article: PMC6389262] [PubMed: 29486713]

2.

Rebholz C, Krawczyk M, Lammert F. Genetics of gallstone disease. Eur J Clin Invest. 2018 Jul;48(7):e12935. [PubMed: 29635711]

3.

Shabanzadeh DM. New determinants for gallstone disease?
. Dan Med J. 2018 Feb;65(2) [PubMed: 29393043]

4.

Del Pozo R, Mardones L, Villagrán M, Muñoz K, Roa S, Rozas F, Ormazábal V, Muñoz M. [Effect of a high-fat diet on cholesterol gallstone formation]. Rev Med Chil. 2017 Sep;145(9):1099-1105. [PubMed: 29424395]

5.

Charfi S, Gouiaa N, Mnif H, Chtourou L, Tahri N, Abid B, Mzali R, Boudawara TS. Histopathological findings in cholecystectomies specimens: A single institution study of 20 584 cases. Hepatobiliary Pancreat Dis Int. 2018 Aug;17(4):345-348. [PubMed: 30173787]

6.

Wilkins T, Agabin E, Varghese J, Talukder A. Gallbladder Dysfunction: Cholecystitis, Choledocholithiasis, Cholangitis, and Biliary Dyskinesia. Prim Care. 2017 Dec;44(4):575-597. [PubMed: 29132521]

7.

Hiwatashi K, Okumura H, Setoyama T, Ando K, Ogura Y, Aridome K, Maenohara S, Natsugoe S. Evaluation of laparoscopic cholecystectomy using indocyanine green cholangiography including cholecystitis: A retrospective study. Medicine (Baltimore). 2018 Jul;97(30):e11654. [PMC free article: PMC6078678] [PubMed: 30045318]

8.

Hirajima S, Koh T, Sakai T, Imamura T, Kato S, Nishimura Y, Soga K, Nishio M, Oguro A, Nakagawa N. Utility of Laparoscopic Subtotal Cholecystectomy with or without Cystic Duct Ligation for Severe Cholecystitis. Am Surg. 2017 Nov 01;83(11):1209-1213. [PubMed: 29183521]

9.

Del Vecchio Blanco G, Gesuale C, Varanese M, Monteleone G, Paoluzi OA. Idiopathic acute pancreatitis: a review on etiology and diagnostic work-up. Clin J Gastroenterol. 2019 Dec;12(6):511-524. [PubMed: 31041651]

10.

Brägelmann J, Barahona Ponce C, Marcelain K, Roessler S, Goeppert B, Gallegos I, Colombo A, Sanhueza V, Morales E, Rivera MT, de Toro G, Ortega A, Müller B, Gabler F, Scherer D, Waldenberger M, Reischl E, Boekstegers F, Garate-Calderon V, Umu SU, Rounge TB, Popanda O, Lorenzo Bermejo J. Epigenome-Wide Analysis of Methylation Changes in the Sequence of Gallstone Disease, Dysplasia, and Gallbladder Cancer. Hepatology. 2021 Jun;73(6):2293-2310. [PubMed: 33020926]

11.

Patel SS, Kohli DR, Savas J, Mutha PR, Zfass A, Shah TU. Surgery Reduces Risk of Complications Even in High-Risk Veterans After Endoscopic Therapy for Biliary Stone Disease. Dig Dis Sci. 2018 Mar;63(3):781-786. [PubMed: 29380173]

12.

Genser L, Vons C. Can abdominal surgical emergencies be treated in an ambulatory setting? J Visc Surg. 2015 Dec;152(6 Suppl):S81-9. [PubMed: 26522504]

13.

Coleman J. Bile duct injuries in laparoscopic cholecystectomy: nursing perspective. AACN Clin Issues. 1999 Nov;10(4):442-54. [PubMed: 10865529]

Disclosure: Mark Jones declares no relevant financial relationships with ineligible companies.

Disclosure: Connor Weir declares no relevant financial relationships with ineligible companies.

Disclosure: Sassan Ghassemzadeh declares no relevant financial relationships with ineligible companies.

Gallbladder stones: types, symptoms and treatment

The gallbladder is an important organ that takes part in the digestive process. It is responsible for the accumulation and storage of bile. With violations in his work, a person begins to be disturbed by pain in the right side of the abdominal cavity and other unpleasant symptoms. One of the reasons why the gallbladder ceases to function normally is the formation of gallstones.

Hard formations result from stagnant bile. During stagnant processes, its individual components precipitate and crystallize. These crystallized formations are gallstones. At first, they do not cause discomfort to the patient, but over the years they increase in size and disrupt the functioning of the gallbladder. If you do not see a doctor in time, a number of complications may occur: blockage of the bile ducts, acute cholecystitis, biliary pancreatitis, fistula formation.

Why do gallstones appear?

Causes that cause thickening and stagnation of bile:

• malnutrition: overeating, abuse of fatty, fried, smoked foods, lack of vegetables and fruits in the diet, prolonged starvation;
• high cholesterol;
• diet high in animal fats;
• diabetes mellitus;
• metabolic disorders;
• presence of parasites;
• overweight;
• hormonal changes in the body – pregnancy, menopause, treatment with drugs containing hormones;
• certain diseases: diabetes mellitus, infectious diseases, biliary dyskinesia, Crohn’s disease, hepatitis, cirrhosis and other liver pathologies;
• long-term treatment with certain drugs;
• taking hormonal contraceptives;
• frequent drinking;
• unfavorable heredity.

Patients who have one or more risk factors should be vigilant about their health and have an abdominal ultrasound examination once a year.

Symptoms of gallstones

At first, gallstone disease is asymptomatic. A person may not be aware of the formation of calculi for years until the problem is detected on a routine ultrasound examination. Pathology can be suspected by the following signs:

• discomfort, heaviness, pain in the right hypochondrium, worse after eating;
• bitter taste in the mouth;
• frequent belching;
• dark urine;
• light-colored feces;
• stool disorders;
• intermittent nausea.

If the stone moves along the duct, pain may be felt in the lower abdomen, radiating to the thigh.

Movement of stones may cause blockage of the bile duct or duodenal papilla. In this case, intestinal colic will occur, which is accompanied by:

• severe pain that may radiate to the back;
• yellowing of the skin, mucous membranes, sclera of the eyes;
• bilious vomiting;
• fever – a symptom indicates the development of an acute inflammatory process.

An attack of colic can last from half an hour to 12 hours. After the stone moves into the duodenum and the bile flow is restored, the pain subsides. However, colic will resume as soon as the next element moves. Therefore, gallstones are a problem, the solution of which cannot be postponed until later. Otherwise, the patient will face complications that require urgent surgical intervention.

What types of stones are found in the gallbladder?

Solid growths in the gallbladder vary in color, shape, size and composition. They are usually round in shape. Stones that fit snugly against each other will be uneven, with edges. The range of sizes varies from small, like sand, to large, filling the bubble cavity completely.

According to their composition, calculi are divided into:

• Cholesterol stones are formed as a result of disorders in the metabolism of cholesterol and bile acids. They have a yellowish, golden or greenish tint. More common in people who are overweight. The formation of such stones is rarely accompanied by an inflammatory process, so their presence goes unnoticed for a long time.
• Bilirubin – formed due to changes in the composition of the blood. More often these are rounded single calculi of a dark color, but there are also multiple calculi of small sizes.
• Calcium – are formed as a result of inflammatory processes in the gallbladder. They have a whitish tint, in addition to calcium, they contain dead epithelial cells, as well as cholesterol.
• Mixed – most common. They have a layered structure, consist of different elements – cholesterol, glycoprotein, bile acids, etc. Mixed stones often cause biliary colic.

Diagnosis of cholelithiasis

The diagnosis is made on the basis of a medical examination, the results of laboratory tests of urine and blood, as well as instrumental studies.

Instrumental methods that make it possible to examine the ducts, assess the localization, size, shape of calculi, determine their composition:

• ultrasound examination of the abdominal cavity;
• magnetic resonance imaging;
• computed tomography;
• cholecystocholangiography – X-ray examination using contrast. Stones that are not detected by X-ray,
• are called X-ray negative.

Examination methods are determined by the doctor based on the symptoms, clinical picture, and the patient’s condition. Further therapeutic tactics depend on the results obtained.

How to treat gallstones?

There are three types of medical tactics for gallstone disease:

Observation – used for asymptomatic course and absence of inflammatory processes.
Conservative therapy – a tactic aimed at dissolving stones with the help of medications or shock wave lithotripsy – destroying stones with a laser or ultrasound.

As medicines the patient is prescribed:

• antispasmodics – reduce pain caused by contraction of the gallbladder;
• drugs that normalize the composition of bile, such as drugs based on ursodeoxycholic acid, such as Ursaklin.
• digestive enzymes;
• cholagogues

For gallstones, treatment with tablets should be agreed with the doctor. The specialist will prescribe the dosage, regimen and duration of taking the drugs. During therapy, the doctor monitors the dynamics with the help of ultrasound. Drug therapy is more likely to be effective in the presence of X-ray negative stones. For large pigmented and calcified calculi, other methods of treatment are required.

• Shock wave lithotripsy is used infrequently. The method is suitable for patients with mild symptoms, high duct patency and small cholesterol formations.
• Surgical treatment – removal of the gallbladder (cholecystectomy). It is used when conservative methods are ineffective.

Cholecystectomy can be performed in two ways:

• by cavitary – used in advanced form of gallstone disease, accompanied by inflammation of the bladder walls;
• laparoscopic – the procedure is performed through small punctures in the abdominal cavity. This is a safer method, after which the patient recovers faster than after abdominal surgery.

With stones in the gallbladder, the doctor prescribes treatment, focusing on the patient’s condition, the number and size of stones, and the presence of an inflammatory process. If the doctor recommends cholecystectomy, do not be afraid and postpone the procedure. The gallbladder is not a vital organ; patients live without it for many years, practically without changing their habitual lifestyle.

Gallbladder stones: treatment with diet

In gallstone disease, the patient must follow a special diet that includes:

• cereals;
• non-acid fruits and vegetables;
• low-fat dairy and sour-milk products;
• lean meats and fish;
• vegetable broth soups;
• vegetable oils.

Food should be steamed, boiled or stewed.

To be excluded from the diet:

• canned food;
• hot spices and condiments;
• sauces;
• strong tea and coffee;
• carbonated water;
• fatty meats;
• hard-boiled eggs;
• smoked products;
• fresh pastries;
• chocolate.

The patient should eat 5 small meals a day. Such nutrition unloads the liver and promotes the outflow of bile.

If you want to know how to get rid of gallstones, contact your general practitioner or gastroenterologist. The doctor will make an accurate diagnosis and select a therapy that will be effective in your situation. Timely diagnosis and treatment guarantee a favorable outcome of the disease.

A modern view on the causes of the formation of stones in the gallbladder

The gallbladder is a reservoir for the accumulation and thickening of bile, which is a complex liquid consisting of 85% water. Bile contains organic and inorganic substances: bile acids; cholesterol; bilirubin; phospholipids; immunoglobulins; non-metal ions; metals and other substances. Gallstones are hardened formations made up of substances found in bile.

Depending on the substance predominant in the composition of gallstones, they are divided into two types. The most common type are cholesterol gallstones yellow-gray (up to 80%). They consist mainly of undissolved cholesterol, but may contain other components. The second type is pigment gallstones , brown or black stones with a predominance of bilirubin.

The exact cause of the formation of gallstones is still being established, according to available data, they appear when the gallbladder occurs excessive concentration of bile and imbalance of substances contained in it .

Causes of gallstones

When there is too much cholesterol in bile

Bile usually contains enough chemicals to dissolve the cholesterol secreted by the liver. But if your liver secretes more cholesterol than bile can dissolve, the excess cholesterol can be converted into crystals and eventually into cholesterol stones.

When there is too much bilirubin in bile

Bilirubin is a chemical produced when red blood cells (erythrocytes) are broken down in the body. Certain conditions can stimulate your liver to produce too much bilirubin, including cirrhosis of the liver, biliary tract infections, and certain types of anemia. Excess bilirubin contributes to the formation of pigment stones.

When there are disorders of gallbladder emptying and stagnation of bile

If the gallbladder is not emptied completely or often enough, bile can become very concentrated, which contributes to sedimentation and the formation of gallstones.

When there is a bacterial infection in the gallbladder

Chronic inflammation in the gallbladder leads to disturbances in its functioning and changes in the composition of bile and the formation of pigmented gallstones.

Risk factors for gallstones

There are factors that increase the risk of gallstones, and they differ depending on the type of stone.

Risk factors for the formation of cholesterol gallstones

• family predisposition;
• female;
• age 40 and older;
• congenital features of the structure of the gallbladder;
• sedentary lifestyle;
• diet high in fat and simple carbohydrates;
• high cholesterol low fiber diet;
• overweight or obese;
• pregnancy;
• fast weight loss.
• type 2 diabetes mellitus;
• taking medications containing estrogen, such as contraceptives or hormonal drugs and drugs that affect the contractility of the gallbladder.

Risk factors for the formation of pigmented gallstones

• old age;
• the presence of diseases of the liver, blood and intestines;
• biliary tract infections and helminths.

How to reduce the risk of gallstones?

You can reduce your risk of gallstones with simple remedies, either on your own or with the help of a doctor.

Do not skip meals . Try to stick to your regular meals every day. Skipping meals or fasting can increase your risk of gallstones.

Lose weight slowly . If you need to lose weight, take your time. Rapid weight loss can increase the risk of gallstones. Aim to lose 0.5-1 kg per week.

Include dietary fiber in your diet .