What are the two main types of gallstones. How do doctors diagnose gallstones. What are the available treatment options for gallstones. Why is surgical removal of the gallbladder often recommended for persistent gallstone problems.

Understanding Gallstones: Types and Symptoms

Gallstones are solid, pebble-like formations that develop in the gallbladder. They can vary in size and composition, leading to different symptoms and treatment approaches. There are two primary types of gallstones:

• Cholesterol stones: These are the most common type, formed primarily from cholesterol.
• Pigment stones: These are composed mainly of bilirubin, a waste product from the breakdown of red blood cells.

The symptoms of gallstones can range from mild discomfort to severe pain. Common indicators include:

• Upper right abdomen pain
• Jaundice (yellowing of the skin and eyes)
• Nausea and vomiting
• Fever and chills
• Dark urine or light-colored stools

Is upper right abdomen pain always indicative of gallstones. While it’s a common symptom, other conditions can cause similar discomfort. A proper medical evaluation is essential for an accurate diagnosis.

Diagnosing Gallstones: Medical Tests and Procedures

When gallstones are suspected, doctors employ various diagnostic tools to confirm their presence and assess their impact. The diagnostic process typically involves:

1. Physical examination: Checking for jaundice and abdominal tenderness
2. Blood tests: To detect signs of infection or obstruction
3. Ultrasound: A non-invasive imaging technique using sound waves
4. CT scans: For a detailed view of internal organs and structures
5. ERCP (Endoscopic Retrograde Cholangiopancreatography): A more advanced procedure for examining the bile ducts

How does an ultrasound help in diagnosing gallstones. Ultrasound is often the first-line diagnostic tool due to its ability to create clear images of the gallbladder, bile ducts, and any stones present. It’s quick, painless, and highly effective in detecting gallstones.

Treatment Options for Gallstones: From Watchful Waiting to Surgery

The treatment approach for gallstones depends on the severity of symptoms and the patient’s overall health. Options include:

1. Watchful Waiting

For asymptomatic or mildly symptomatic gallstones, doctors may recommend a wait-and-see approach. Many individuals who experience a single gallstone attack never have a recurrence, as the stone may dissolve or become dislodged naturally.

2. Nonsurgical Therapies

When surgery is not an option, alternative treatments may be considered:

• Oral dissolution therapy: Using medications like Actigall (ursodiol) to dissolve cholesterol stones
• Shock wave therapy: Employing high-frequency sound waves to break up stones
• ERCP stone removal: Extracting stones during an ERCP procedure

Can all gallstones be treated with nonsurgical methods. No, these techniques are primarily effective for cholesterol stones and may not work for pigment stones or calcified formations. Additionally, they don’t prevent future stone formation.

3. Surgical Removal of the Gallbladder

Cholecystectomy, or surgical removal of the gallbladder, is the most definitive treatment for persistent gallstone problems. It’s considered one of the safest surgical procedures, with approximately 750,000 Americans undergoing the operation annually.

The Role of the Gallbladder and Life After Its Removal

The gallbladder serves as a storage organ for bile, concentrating and releasing it to aid in fat digestion. However, it’s not essential for survival. After gallbladder removal:

• Bile flows directly from the liver to the small intestine
• Patients may experience temporary diarrhea as the body adjusts
• The ability to digest large fatty meals may be slightly impaired

Does gallbladder removal affect long-term health. While some dietary adjustments may be necessary, most people lead normal, healthy lives without a gallbladder. The procedure eliminates the risk of future gallstone formation in the gallbladder.

Preventing Gallstone Recurrence: Lifestyle and Dietary Considerations

While gallbladder removal prevents future gallstones in that organ, those who undergo nonsurgical treatments or opt for watchful waiting should consider lifestyle changes to reduce the risk of recurrence:

• Maintain a healthy weight
• Eat a balanced diet rich in fiber
• Stay hydrated
• Exercise regularly
• Limit high-fat and high-cholesterol foods

Can dietary changes alone prevent gallstone formation. While a healthy diet can reduce the risk, other factors like genetics and certain medical conditions also play a role in gallstone development. A comprehensive approach to health is most effective.

Understanding ERCP: A Diagnostic and Therapeutic Tool

Endoscopic Retrograde Cholangiopancreatography (ERCP) is a valuable procedure in the management of gallstone-related issues. This technique serves dual purposes:

Diagnostic Function

ERCP allows doctors to visualize the bile ducts and identify any obstructions or abnormalities. The process involves:

1. Sedating the patient and numbing the throat
2. Inserting a flexible endoscope through the mouth and into the small intestine
3. Injecting dye into the bile duct
4. Taking X-rays to observe the flow of dye and detect any blockages

Therapeutic Application

Beyond diagnosis, ERCP can be used to treat certain gallstone problems:

• Removing stones lodged in the bile duct
• Widening narrowed ducts
• Placing stents to keep ducts open

How long does an ERCP procedure typically take. The entire process usually lasts about an hour, though this can vary depending on the complexity of the case and whether therapeutic interventions are needed.

Complications and Risks Associated with Gallstones

While many gallstones remain asymptomatic, they can lead to serious complications if left untreated:

• Cholecystitis: Inflammation of the gallbladder
• Choledocholithiasis: Stones blocking the common bile duct
• Pancreatitis: Inflammation of the pancreas due to stone blockage
• Cholangitis: Infection of the bile duct system
• Gallbladder cancer: A rare but serious potential complication

When should someone seek immediate medical attention for gallstone symptoms. Severe abdominal pain, persistent fever, or signs of jaundice warrant urgent medical evaluation to prevent potential complications.

Emerging Research and Future Treatments for Gallstones

The field of gallstone management continues to evolve, with ongoing research into new treatment modalities and prevention strategies:

Improved Dissolution Therapies

Scientists are exploring more effective medications to dissolve gallstones without surgery. These may offer faster results and work on a broader range of stone types.

Minimally Invasive Techniques

Advancements in laparoscopic and robotic surgery are making gallbladder removal even safer and less invasive, with quicker recovery times.

Genetic Research

Understanding the genetic factors contributing to gallstone formation may lead to personalized prevention strategies and targeted treatments.

Microbiome Studies

Investigating the role of gut bacteria in gallstone development could open new avenues for probiotic-based preventive measures.

How might future treatments change the landscape of gallstone management. As research progresses, we may see a shift towards more personalized, less invasive treatments that address the root causes of gallstone formation rather than simply removing the gallbladder.

Gallstones remain a common health issue, affecting millions worldwide. While current treatments, especially surgical options, are highly effective, ongoing research promises to bring even more refined and tailored approaches to gallstone management. As our understanding of the condition deepens, patients can look forward to a future with more diverse treatment options and improved preventive strategies.

Gallstones Diagnosis, Tests, & Treatments

Written by WebMD Editorial Contributors

• How Do I Know if I Have Gallstones?
• What Are the Treatments for Gallstones?
• Conventional Medicine for Gallstones
• Gallstones and Watchful Waiting
• Nonsurgical Therapy for Gallstones
• Surgery to Remove the Gallbladder
• More

If your symptoms suggest a gallstone problem, your doctor might first examine your skin for jaundice, and then feel your abdomen to check for tenderness. A blood test may reveal evidence of an obstruction.

Because other digestive problems, such as an infection of the duct, can produce symptoms similar to those of a gallstone attack, the doctor may also run other tests to determine if gallstones are in fact the culprit.

The most common technique is an ultrasound exam. This quick, painless procedure uses high-frequency sound waves to create pictures of the gallbladder, bile duct, and their contents. CT scans are also sometimes done to look at the anatomy of your internal organs.

A more complicated test may be used if the doctor suspects that a gallstone is lodged in a bile duct. Commonly known by the acronym ERCP, this test allows the doctor to look at the bile duct through a small flexible tube called an endoscope. The doctor sprays the back of the patient’s throat with an anesthetic drug to prevent gagging, sedates the patient, and passes the endoscope into the mouth, through the stomach, and into the area of the small intestine where the bile duct enters. Dye is injected through the tube and into the bile duct, and then the doctor takes X-rays. Stone removal can be done during this procedure as well. The procedure takes about an hour.

In most cases, treatment of gallstones is considered necessary only if you are having symptoms. Of the various conventional treatments that are available, surgical removal of the gallbladder is the most widely used. Some alternative treatments have also been found to be effective in alleviating the symptoms of troublesome gallstones.

When deciding what course of action to take for symptomatic gallstones, doctors usually choose from among three main treatment options: Watchful waiting, nonsurgical therapy, and surgical removal of the gallbladder.

Though a gallstone episode can be extremely painful or frightening, almost a third to half of all people who experience an attack never have a recurrence. In some cases, the stone dissolves or becomes dislodged and thereby resumes its “silence.” Because the problem may solve itself without intervention, many doctors take a wait-and-see approach following the initial episode.

Even when the patient has had repeated gallstone episodes, the doctor may postpone treatment or surgery because of other health concerns. If your surgery has been delayed, you should remain under a doctor’s care and report any recurrences of gallstone symptoms immediately.

If you are unable or unwilling to go through surgery for a gallstone problem that requires treatment, your doctor may recommend one of several noninvasive techniques. Note that though these methods may destroy symptom-causing gallstones, they can do nothing to prevent others from forming, and recurrence is common.

Some gallstones can be dissolved through the use of a bile salt, although the procedure can be used only with stones formed from cholesterol and not from bile pigments. The drug Actigall (ursodiol) is taken as a tablet; depending on its size, the gallstone may take months or even years to go away. Because some stones are calcified, this treatment often doesn’t work.

Another nonsurgical technique, shock wave therapy, uses high-frequency sound waves to fragment the stones. Bile salt is administered afterward to dissolve small pieces. This therapy is rarely used.

Doctors can also attempt to remove gallstones during an ERCP. During the procedure an instrument is inserted through the endoscope to attempt removal of the stone.

While these therapies may work for some, all of the above nonsurgical therapies are usually unsuccessful long term (since recurrence is common) and are rarely advised in clinical practice.

While the gallbladder serves an important function, it is not essential for a normal, healthy life. When gallstones are persistently troublesome, doctors often recommend removing the organ entirely. This operation is considered among the safest of all surgical procedures. Each year approximately 750,000 Americans have their gallbladder removed. It is also the only treatment method that eliminates the possibility that other gallstones will develop in the future.

When the gallbladder has been removed, bile flows directly from the liver into the small intestine, and this sometimes leads to diarrhea. Because bile no longer accumulates in the gallbladder, quantities of the digestive fluid cannot be stored up and used to break down an especially fatty meal. This condition is not considered serious, however, and can be corrected by simply limiting fat in the diet.

In the past, removal of the gallbladder was done through traditional “open” surgery, which requires surgeons to make a large incision in the abdomen. Patients faced a two- or three-day hospital stay plus several weeks of recovery at home.

Today, however, the most commonly used surgical technique is a much simpler approach known as laparoscopic cholecystectomy. The doctor makes several small incisions in the abdomen, then uses special pencil-thin instruments to remove the gallbladder. A tiny microscope and video camera, snaked through the incision to the site, allow the surgeon to view the operation.

Laparoscopic surgery is highly effective and very safe. It has reduced the hospital stay to a day or two. Patients report less pain and are generally able to resume a normal lifestyle in a short period of time. However, people who are obese or who have a severe infection or inflammation in the gallbladder may still be considered candidates for traditional open surgery.

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Gallstones (Cholelithiasis) – StatPearls – NCBI Bookshelf

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

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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

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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]

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

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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]

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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]

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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]

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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]

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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]

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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]

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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]

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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]

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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]

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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.

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.

Gallstone risk factors

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

Risk factors for cholesterol gallstones

• family predisposition;
• female;
• age 40 and older;
• congenital features of the structure of the gallbladder;
• sedentary;
• 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 fiber in your diet . It is recommended to consume up to 30 g of dietary fiber per day. Most fiber is found in cereals, slightly less in fruits. Wholemeal bread, whole-grain pasta, cereals from whole grains or large cereals are the basis of nutrition for a patient at risk of gallstone disease.

Maintain a healthy weight . To lose weight, use a reduced-calorie diet and increase physical activity. Once you’ve lost your weight, continue to eat healthy and stay active.

Seek medical attention . If there is a predisposition to the development of gallstone disease, the observation of a gastroenterologist and preventive therapy in most cases will help to avoid the formation of stones in the gallbladder.

Gallstones and treatments

Gallstones and treatments

Gallstone disease (GSD) is a condition in which gallstones form in the gallbladder due to bile stasis and salt imbalance. Without surgery, gallbladder stones create an obstacle to the flow of bile into the duodenum, and the full breakdown of fats becomes impossible.

Irregular nutrition, starvation, overnutrition, hormonal drugs, low mobility, endocrine imbalance provoke the formation of stones. Dense particles are formed in the bile, which are gradually deposited, compacted and eventually lead to the formation of conglomerates (calculi).

The main components of stones are cholesterol, bilirubin and calcium salts.

The process is gradual. At first, nothing bothers a person. GSD is manifested by biliary colic, when, due to food stress or mechanical displacement, the stone leaves the bladder and clogs the mouth of the bile duct. Bile continues to be produced, the bladder is stretched, the breakdown of food is disturbed. Colic develops – this is an extremely painful condition, which in most cases requires urgent removal of the bladder.

When gallstones formed in the gallbladder – what to do? In this matter, the main thing is not to delay the consultation of a doctor.

Symptoms of gallstones

For a very long time, sometimes decades, gallstones flow without symptoms.

However, the following are warning signs:

• bitterness in the mouth after eating or always present;
• feeling of heaviness on the right under the ribs;
• frequent eructations interspersed with nausea.

The most significant symptom of a gallstone is biliary colic. A sharp pain appears in the right upper abdomen, which gradually increases. The pain radiates to the right arm, collarbone or even to the back. Bitterness in the mouth, excruciating nausea and vomiting joins, but this does not make it any easier. A small stone can reach the duodenum and then pass out with feces.

If this does not happen, obstructive jaundice develops – bile is absorbed into the blood. The bubble becomes inflamed, bedsores or suppuration may form inside. The only way out is to remove stones from the gallbladder.

Causes of stone formation

The exact causes are not fully understood, but doctors are increasingly leaning in favor of the hereditary theory. Both the composition of bile and the structural features of the bile-forming system are important. In the vast majority of cases, patients with gallstone disease are overweight. Risks also increase as animal protein and fat intake increases. Where people eat mainly plant foods and do not overeat, cholelithiasis practically does not occur.

The onset of the disease is the formation of biliary sludge – thick bile. At some point, bilirubin ceases to dissolve completely, and at this stage small stones are formed, which only increase in volume over time. With large calculi, surgery is indispensable.

Types of gallstones and their sizes

There are 4 types of stones:

• cholesterol – formed more often than others;
• pigmented or bilirubin;
• calcareous or calcium;
• mixed.

Often, different types of stones are found in one person at the same time. Their shape is also different – spherical, needle-shaped, oval, faceted, etc. The sizes of calculi vary widely – from small, similar to sand, to huge weighing up to 80 g, occupying the entire bladder. It is possible to remove stones in the gallbladder with surgical treatment – surgery.

Diagnosis of cholelithiasis

To establish the final diagnosis, several methods are used:

• ultrasound scan;
• cholecystoangiography;
• computed tomography;
• nuclear magnetic resonance.

If gallstones are found and there are symptoms, then the optimal treatment is surgery.

Methods of treatment

Treatment for gallstones is surgery. Modern treatment is performed laparoscopically, when endoscopic instruments are inserted into small incisions in the anterior abdominal wall. After such an operation, there are no unaesthetic scars. It is enough to stay in the hospital for 2 or 4 days. The technique of laparoscopic operations for the removal of stones from the gallbladder, used in Best Clinic, has been developed to the smallest detail, so there are practically no complications.

Can a gallstone be cured without surgery? If the characteristics of the disease allow, use lithotripsy (ultrasonic crushing of stones). Stones turn into sand and pass out naturally with feces.

Can gallstones dissolve? There are preparations of bile acids and extracts of medicinal plants that contribute to the destruction of stones. Drug treatment is used for single stones no larger than 2 cm in size.

A common folk remedy for gallstones is lemon juice in a glass of hot water. Apply olive oil, a decoction of red beets, a decoction of dill. However, these folk methods are beneficial only in combination with traditional medicine.

The attending physician will help you choose the best way to treat gallstone disease, taking into account the individual characteristics of the patient’s body.

Prevention of cholelithiasis

Prevention that slows down the formation of gallstones is regular meals in fractional portions 5-6 times a day with a decrease in the amount of refractory fats of animal origin. It is advisable to reduce weight, do not overcool, perform moderate physical activity.