Where are gallstones located. Symptoms of gallstones. Causes of gallstones. Treatment options for gallstones. All you need to know about gallstones.

Understanding Gallstones: Location and Formation

Gallstones are solid deposits that form within the gallbladder, a small organ located in the upper right abdomen, just beneath the liver. These stones are created when substances found in bile, such as cholesterol and bilirubin, harden and solidify. The gallbladder’s role is to store and concentrate bile, a fluid that aids in the digestion of fats. When the balance of substances in bile is disrupted, gallstones can form.

Symptoms of Gallstones: Recognizing the Warning Signs

Not all gallstones cause noticeable symptoms. In fact, about 80% of people with gallstones are asymptomatic, meaning they experience no pain or discomfort. However, when gallstones block the bile duct or cause inflammation in the gallbladder, it can lead to a range of symptoms, including:

• Pain in the upper right abdomen or center of the stomach, often after eating fatty foods
• Severe, persistent pain that can last for several hours
• Fever, rapid heartbeat, and yellowing of the skin and eyes (jaundice)
• Itchy skin, diarrhea, and chills

It’s important to seek medical attention if you experience any of these symptoms, as they may indicate a more serious underlying condition, such as a gallbladder infection or inflammation of the liver or pancreas.

Causes of Gallstones: Understanding the Risk Factors

The exact cause of gallstone formation is not entirely clear, but several factors can contribute to their development:

1. Excess cholesterol in bile: When the liver produces more cholesterol than the bile can dissolve, it can lead to the formation of yellow cholesterol stones.
2. Increased bilirubin levels: Certain conditions that cause the liver to produce more bilirubin, a byproduct of red blood cell breakdown, can result in the formation of dark brown or black pigment stones.
3. Concentrated bile: If the gallbladder fails to empty its bile content properly, the bile can become overly concentrated, leading to stone formation.

Additional risk factors for gallstones include being female, being overweight or obese, having a family history of gallstones, and rapid weight loss or pregnancy.

Treating Gallstones: Surgical and Non-Surgical Options

The treatment for gallstones depends on whether they are causing symptoms and the severity of the condition. For those with asymptomatic gallstones, no treatment may be necessary. However, if the stones are causing pain or other complications, the following treatment options may be considered:

• Cholecystectomy (gallbladder removal): This is the most common treatment for symptomatic gallstones. The procedure can be performed laparoscopically or through open surgery, depending on the individual case.
• Medication: In rare cases, medication may be used to dissolve gallstones, but this approach is less common and often less effective than surgery.
• Non-surgical procedures: For individuals who are not candidates for surgery, alternative treatments such as extracorporeal shock wave lithotripsy (ESWL) or percutaneous cholecystostomy may be considered to break up or remove the stones.

It’s important to note that if gallstones are left untreated, they may recur, even with additional non-surgical treatment. Therefore, many healthcare providers recommend surgical removal of the gallbladder as the most effective long-term solution for symptomatic gallstones.

Preventing Gallstones: Lifestyle Modifications and Dietary Changes

While there is no surefire way to prevent the formation of gallstones, certain lifestyle and dietary changes may help reduce the risk:

• Maintain a healthy weight: Excess weight and rapid weight loss are both risk factors for gallstone development.
• Eat a balanced, low-fat diet: Limiting the intake of high-fat and high-cholesterol foods can help prevent the buildup of substances that can lead to gallstone formation.
• Exercise regularly: Regular physical activity can help maintain a healthy weight and improve the function of the gallbladder.
• Manage underlying health conditions: Conditions like diabetes, high blood pressure, and high cholesterol may increase the risk of gallstones and should be properly managed.

When to Seek Medical Attention for Gallstones

If you are experiencing any symptoms that may be related to gallstones, it’s important to seek medical attention promptly. Your healthcare provider can perform various tests, such as imaging scans or blood tests, to diagnose the presence and severity of gallstones. Early diagnosis and appropriate treatment can help prevent serious complications and ensure a better long-term outcome.

Conclusion

Gallstones are a common health condition that can cause a range of symptoms, from mild discomfort to severe pain and complications. Understanding the location, causes, and treatment options for gallstones is essential for managing this condition effectively. By working closely with your healthcare provider, you can develop a personalized plan to address your gallstone-related concerns and maintain optimal digestive health.

Symptoms, Causes, Treatment, and More

Gallstones are deposits of digestive fluid made of solidified substances found in bile, like cholesterol. They are common and may or may not produce symptoms. People with symptoms usually need to have their gallbladders taken out.

Read on to learn more about gallstones, the symptoms they can cause, and how to treat them.

Your gallbladder is a small organ in your upper right abdomen, right below your liver. It’s a pouch that stores bile, a green-yellow liquid that helps digestion. Issues with your gallbladder typically occur when something is blocking its bile duct—like a gallstone.

Most gallstones are created when substances found in bile, like cholesterol, harden. Gallstones are very common and routinely asymptomatic.

However, about 10 percent of people who are diagnosed with gallstones will develop noticeable symptoms within 5 years.

Photo: Bruce Blaus | Wikimedia Commons | https://commons.wikimedia.org/wiki/File:Gallstones. png

Gallstones can lead to pain in the upper right abdomen or the center of your stomach. You may experience gallbladder pain from time to time after you eat foods that are high in fat, such as fried foods, but the pain can occur at almost any time.

Pain caused by gallstone issues usually lasts for only a few hours, but it can feel severe.

If gallstones are left untreated or unidentified, the symptoms may increase to include:

• a high temperature
• rapid heartbeat
• yellowing of the skin and whites of the eyes (jaundice)
• itchy skin
• diarrhea
• chills
• confusion
• a loss of appetite

These symptoms can be signs of a gallbladder infection, or inflammation of the gallbladder, liver, or pancreas.

Because gallstone symptoms may mimic the symptoms of other serious issues like appendicitis and pancreatitis, no matter what, if you’re dealing with one or more of these issues — it’s time to see a doctor or get yourself to the ER.

If you need help finding a urologist, then check out our FindCare tool here.

Asymptomatic gallstones

Gallstones themselves don’t cause pain. Rather, pain occurs when gallstones block the movement of bile from the gallbladder.

According to the American College of Gastroenterology, about 80 percent of people who have gallstones have “silent gallstones.” This means they don’t experience pain or have symptoms. In these cases, your doctor may discover the gallstones from X-rays or during abdominal surgery.

The actual cause of gallstones is thought to be due to a chemical imbalance of bile inside of the gallbladder. While researchers still aren’t clear about what exactly causes that imbalance to happen, there are a few possible reasons:

Too much cholesterol in your bile

Having too much cholesterol in your bile can lead to yellow cholesterol stones. These hard stones may develop if your liver makes more cholesterol than your bile can dissolve.

Too much bilirubin in your bile

Bilirubin is a chemical produced during the normal breakdown of red blood cells. After it’s created, it passes through the liver and is eventually excreted out of the body.

Some conditions, such as liver damage and certain blood disorders, cause your liver to produce more bilirubin than it should. Pigment gallstones form when your gallbladder can’t break down the excess bilirubin. These hard stones are often dark brown or black.

Concentrated bile due to a full gallbladder

Your gallbladder needs to be able to empty its bile to function properly. If it fails to empty its bile content, the bile becomes overly concentrated, which can cause stones to form.

Most of the time, you won’t need treatment for gallstones unless they cause you pain. Sometimes you can pass gallstones without even noticing. If you’re in pain, your doctor will likely recommend surgery. In rare cases, medication may be used.

If you’re at high risk for surgery complications, there are a few nonsurgical ways to attempt to treat gallstones. However, if surgery isn’t performed, your gallstones may come back — even with additional treatment. This means you may need to keep an eye on your condition for the majority of your life.

Surgery

Cholecystectomy, which is surgery to remove the gallbladder, is one of the most common operations performed on adults in the United States. Because the gallbladder isn’t an essential organ, it’s possible to live a healthy life without it.

There are two types of cholecystectomy:

• Laparoscopic cholecystectomy. This is a common surgery that requires general anesthesia. The surgeon will usually make three or four incisions in your abdomen. They’ll then insert a small, lighted device into one of the incisions, check for stones, and carefully remove your gallbladder. You can usually go home on the day of the procedure or the day after if you have no complications.
• Open cholecystectomy.This surgery is typically performed when the gallbladder is inflamed, infected, or scarred. This surgery may also happen if problems occur during a laparoscopic cholecystectomy.

You may experience loose or watery stools after gallbladder removal. Removing a gallbladder involves rerouting the bile from the liver to the small intestine. Bile no longer goes through the gallbladder and it becomes less concentrated. The immediate result is a laxative effect that can cause diarrhea, but this issue should resolve on its own for most people.

Nonsurgical treatments

If surgery can’t be performed, such as if the patient is a much older individual, there are a few other ways doctors can try to get rid of your gallstones.

• Oral dissolution therapy typically includes using the medications ursodiol (Actigall) and chenodiol (Chenix) to break up gallstones. These medications contain bile acids, which work to break up the stones. This treatment is best suited for breaking up cholesterol stones and can take many months or years to work completely.
• Shock wave lithotripsy is another option. A lithotripter is a machine that generates shock waves that pass through a person. These shock waves can break gallstones into smaller pieces.
• Percutaneous drainage of the gallbladder involves placing a sterile needle into the gallbladder to aspirate (draw out) bile. A tube is then inserted to help with additional drainage. This procedure isn’t typically a first line of defense and tends to be an option for individuals who may not be suited for other procedures.

Some risk factors for gallstones are related to diet, while other factors are not as controllable. Uncontrollable risk factors are things like age, race, sex, and family history.

Lifestyle risk factors

• living with obesity
• a diet high in fat or cholesterol and low in fiber
• undergoing rapid weight loss
• living with type 2 diabetes

Genetic risk factors

• being born female
• being of Native American or Mexican descent
• having a family history of gallstones
• being 60 years or older

Medical risk factors

• living with cirrhosis
• being pregnant
• taking certain medications to lower cholesterol
• taking medications with a high estrogen content (like certain birth controls)

While some medications may increase your risk of gallstones, don’t stop taking them unless you have discussed it with your doctor and have their approval.

Your doctor will perform a physical examination that includes checking your eyes and skin for visible changes in color. A yellowish tint may be a sign of jaundice, the result of too much bilirubin in your body.

The exam may involve using diagnostic tests that help your doctor see inside your body. These tests include:

• Ultrasound. An ultrasound produces images of your abdomen. It’s the preferred imaging method to confirm that you have gallstone disease. It can also show abnormalities associated with acute cholecystitis.
• Abdominal CT scan. This imaging test takes pictures of your liver and abdominal region.
• Gallbladder radionuclide scan. This important scan takes about one hour to complete. A specialist injects a radioactive substance into your veins. The substance travels through your blood to the liver and gallbladder. On a scan, it can reveal evidence to suggest infection or blockage of the bile ducts from stones.
• Blood tests. Your doctor may order blood tests that measure the amount of bilirubin in your blood. The tests also help determine how well your liver is functioning.

To help improve your condition and reduce your risk of gallstones, try these tips:

• Eat fewer refined carbs (like cookies and white bread) and less sugar.
• Increase your intake of healthy fats, like fish oil and olive oil, which may help your gallbladder contract and empty on a regular basis.
• Eat the proper amount of fiber per day (women need about 25 grams a day, men need about 38 grams a day).
• Get some sort of physical activity every day.
• Keep yourself properly hydrated.

If you plan to lose weight, do it slowly. Rapid weight loss may increase your risk of gallstones and other health problems.

While there is no foolproof way to completely prevent gallstones, cholesterol seems to play a major role in their formation. If you have a family history of gallstones, your doctor may advise you to limit foods with a high saturated fat content. Some of these foods include:

• fatty meat, like sausage and bacon
• cakes and cookies
• lard and cream
• certain cheeses

Because people living with obesity are more predisposed to gallstones, keeping your weight within a moderate range is another way to limit the possibility of their formation.

If your doctor has diagnosed you with gallstones and decides you need surgery to remove them or your gallbladder, the outlook is often positive. In most cases of stone removal, stones don’t return.

If you aren’t able to have surgery and decide to take medication to dissolve the stones, the gallstones can return, so you and your doctor will need to monitor your progress.

If your gallstones aren’t causing symptoms, you will most likely not need to do anything. Still, you may want to make lifestyle changes to prevent them from getting bigger and causing problems.

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]

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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]

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.

Cholelithiasis – Clinic 29

Gallstone disease (GSD) is a disease in which stones form in the gallbladder or bile ducts. Gallstone disease has been known since ancient times. Galen also discovered gallstones during the autopsy of corpses. Mentions of cholelithiasis are found in the writings of doctors of the Renaissance. Currently, every tenth inhabitant of our planet suffers from gallstone disease, and this disease of civilization is becoming a social problem.

Causes of cholelithiasis

Gallstone disease in both adults and children is a multifactorial disease. The main factors are:

• Power failure
• Poor quality drinking water
• Heredity
• Physical inactivity
• Bad habits
• Disruption of intestinal microflora
• Stress
• Uncontrolled intake of drugs, etc. , that is, all those factors that lead to metabolic disorders, especially cholesterol metabolism.

Leading links in the process of stone formation: stagnation of bile in the gallbladder and an increase in the concentration of salts in bile due to metabolic disorders.

Can provoke gallstone disease:

• overeating, starvation, irregular meals;
• sedentary lifestyle, especially sedentary work;
• pregnancy;
• taking hormonal contraceptives;
• obesity;
• biliary dyskinesia;
• diseases of the pancreas.

Clinical picture

There are three variants of the clinical picture of cholelithiasis:

• asymptomatic lithiasis;
• clinical manifestation, manifested by abdominal pain and dyspeptic disorders;
• gallstone colic.

Asymptomatic stone carrying is assumed when there are no complaints, and stones in the gallbladder (ducts) are an incidental diagnostic finding, more often on ultrasound. Unfortunately, the stones do not dissolve by themselves, and the disease will manifest itself in other forms over time.

Abdominal pain and dyspeptic disorders are the main complaints. In adults, pain is usually in the right hypochondrium, more often in the form of a feeling of heaviness and is provoked by a violation of the diet (overeating, fatty, fried foods). The nature of the pain depends on the size of the stones. Dull, drawing, vague pains are characteristic of patients with single stones or large stones. Multiple, small, easily moving stones, as a rule, give acute paroxysmal pain – gallstone colic.

Sometimes a small stone passes from the gallbladder into the bile ducts. In this case, an attack of gallstone disease occurs: there is a sharp pain in the right hypochondrium or in the upper abdomen. It can “give” to the right collarbone, right arm or back under the shoulder blade. In this case, bitterness appears in the mouth, nausea and vomiting, which does not bring relief, the sclera of the eyes may turn yellow. If the stone (with a relatively small size) was able to bypass the ducts and fall into the duodenum, the attack stops on its own, and the stone comes out with feces. Otherwise, there is a blockage of the biliary tract and there is a danger of developing acute cholecystitis and mechanical (subhepatic) jaundice. In this case, in addition to the typical picture of colic, yellowness of the skin, discolored stools, and dark urine appear. Pain can spread to other areas of the upper abdomen, often there are “girdle” pains – a sign of blockage not only of the biliary tract, but also of the pancreatic duct. Obturation (blockage) of the excretory ducts is a very dangerous condition!

Diagnosis of cholelithiasis

Diagnosis is based on the clinical picture, on examination of the patient – the doctor can determine tenderness at specific points, on changes in blood and urine tests in the presence of inflammation in the gallbladder and / or a violation of the outflow of bile. Ultrasound reveals formations in the gallbladder, but with symptoms of severe cholecystitis (inflammation), stones may not be visible, ultrasound does not always detect stones that have entered the ducts. Then X-ray methods of research are used: retrograde cholecystopancreatography (RCPG) is the most common method.

Treatment of cholelithiasis

The tactics of treatment of cholelithiasis is determined by the clinical picture, the position of the stones and the timing of the patient’s request for medical help. Non-surgical methods of treatment are rarely used, mainly in children during the period of hormonal instability, in adults in the preoperative period. In case of cholelithiasis, it is prescribed:

• diet with the exception of fatty, fried, smoked, spicy. Food should be fractional, without overeating. Particular importance is attached to the use of vegetables and fruits, wheat bran and other foods containing dietary fiber. They bind bile acids in the intestine, which promotes their synthesis in the liver.
• motor mode: we avoid both hypodynamia and excessive physical exertion. Walking, table tennis, billiards are shown.
• Cholagogue preparations, herbs and tubes are contraindicated!

Surgical treatment

If you have applied for a planned appointment outside the acute phase of gallstone disease, the stones are located only in the gallbladder, and not in the ducts, then you will perform a laparoscopic cholecystectomy (removal of the gallbladder). If stones are localized only in the gallbladder, radical surgery – cholecystectomy in most cases leads to a permanent cure for cholelithiasis. Cholecystectomy is a pathogenetically substantiated operation: the shock organ is removed, i.e. already a defective organ with impaired function and a constant source of infection. All this leads to an acceleration of the circulation of bile acids between the intestines and the liver, a decrease in the stone-forming properties of hepatic bile, and the prevention of the formation of gallstones.

If you delayed the operation for cholelithiasis or tried to “expel” the stones and there was an obstruction of the biliary tract. Such a situation can end with a laparotomy (large abdominal incision), sometimes even with the removal of part of the biliary tract and the imposition of various non-physiological, but vital, connections between organs for the outflow of bile.

Do not be afraid of the operation! The only radical way to treat gallstone disease is to remove the diseased gallbladder. Currently, a special technique has been developed for laparoscopic surgery (the operation is performed using several punctures of the abdominal wall). It is less traumatic, and the patient can get up on the day of the operation. The cosmetic effect is also important – the absence of seams on the body. This issue is especially of concern to girls, because no one wants past illnesses and operations to be read on his body.
After removal of the gallbladder, you can safely return to normal life and practically do not adhere to any diet.

Complications of cholelithiasis

– Infections. The most serious complication of acute cholecystitis caused by gallstones is infection, which occurs in about 20% of cases.

– Gangrene and abscess. Severe inflammation can cause abscess and necrosis (destruction) of tissue in the gallbladder, leading to gangrene. At high risk are men over 50 who have a history of cardiovascular disease.

– Perforation (rupture) of the gallbladder. An estimated 10% of cases of acute cholecystitis due to gallstones have gallbladder perforation, a life-threatening condition. In general, it occurs in people who have not sought help for too long, or in people who do not respond to treatment. Gallbladder perforation is most common in people with diabetes. After the wall of the gallbladder has been perforated, the pain may temporarily decrease. This dangerous delusion threatens with the development of peritonitis and the spread of infection into the abdominal cavity.

– Empyema. Pus in the gallbladder (empyema) occurs in 2 to 3% of patients with acute cholecystitis. Patients usually experience abdominal pain for more than 7 days. Physical examination often does not always immediately reveal the cause. Empyema can be life-threatening, especially if the infection spreads to other parts of the body.

– Fistula. In some cases, inflammation of the gallbladder spreads and leads to perforation of nearby organs, such as the small intestine. In such cases, a fistula is formed between the organs, which is a channel or opening. Sometimes, in such cases, gallstones may actually pass into the small intestine. This can be very serious and requires immediate surgery.

— Gallstone obstruction. Gallstone blockage of the bowel is known as gallstone ileus. It primarily occurs in patients over 65 years of age and can sometimes be fatal. Depending on where the stone is located, surgery may be required to remove it.

– Infection of the common bile duct (cholangitis). Infection of the common bile duct is a very dangerous serious disease. If antibiotics are given immediately, the infection is cured in 75% of patients. If cholangitis is not stopped, the infection can spread and become life-threatening.

– Pancreatitis. Common bile duct stones are responsible for most cases of pancreatitis (inflammation of the pancreas).

– Cancer of the gallbladder. Gallstones occur in about 80% of people with gallbladder cancer. There is a strong relationship between gallbladder cancer and gallstone disease, chronic cholecystitis, and inflammation. Symptoms of gallbladder cancer usually do not appear until the disease has reached the last stage, and may include weight loss, anemia, recurrent vomiting, and foreign body sensation in the abdomen. However, this cancer is very rare, even among people with gallstones.

– Porcelain gallbladder. The gallbladder is called porcelain when its walls are calcified, i.e. coated with calcium. Porcelain gallbladder is associated with a very high risk of cancer. This condition may develop due to a chronic inflammatory response, which may, in fact, be responsible for the risk of developing cancer. The risk of developing cancer also depends on the presence of specific factors, such as partial calcification of the inner lining of the gallbladder.

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Diagnosis and treatment of gallstones : Armedical

Treatment in Israel
State
hospital
Ichilov-Surasky. Official representative.

The gallbladder can form gallstones, which are pieces of hard material like crystals that form directly in the gallbladder. These pieces can be of different shapes, sizes, and presented in different quantities.

The gallbladder is a pear-shaped organ. It is located in the upper right side of the abdomen under the liver. Its main purpose is the accumulation of bile and its excretion at the right time through the bile ducts into the intestines. As you know, bile plays a supporting role in the process of digestion.

Bile is a liquid produced continuously by the liver and is brownish yellow in color. It contains water, bile salts, bilirubin, bile pigments, which gives bile its characteristic color. The amount of bile that the liver can produce per day is up to 3 cups. In turn, the gallbladder is able to store up to 1 cup of bile.

The presence of stones in the gallbladder usually does not cause serious discomfort or pain, but the danger is that they can travel through the bile ducts and block them. And this leads to violations of the outflow of bile and obstruction of the biliary tract.

In 80% of patients, gallstones are yellow, white or light in color due to their calcium and cholesterol content. The remaining 20% ​​are dark-colored stones, which contain bilirubin, which is insoluble in water. 85% of patients have cholesterol-type stones.

In terms of stone size, gallstones can be as small as a grain of sand. But they can also reach large sizes, comparable to the size of a ping-pong ball. There are times when one large stone can form in the gallbladder, and there are also an incredible number (up to a thousand) of small stones.

Stones in the gallbladder – the causes of the appearance

In the course of practice and study of the problem of gallstone disease, the specialists of the Ichilov Hospital made conclusions regarding the main causes of its occurrence:

• hereditary factors;
• overweight and sedentary;
• irrational diet and improper eating habits;
• chemical processes in the liver;
• dysmotility of the gallbladder, etc.

Cholesterol stones are formed if the bile contains an excess amount of cholesterol and there is a lack of bile salts, and also when there are proteins or bile in the liver. Also, another reason for the formation of stones is incomplete emptying of the gallbladder.

Symptoms of gallstone disease

Often, gallstone disease can be asymptomatic. But sometimes there may be pain in the upper abdomen on the right, in the right shoulder blade, chest or back. Nausea or vomiting may also be felt. There can be different intervals between such attacks – both a week and a year.
Even if there are no symptoms of the disease, it still needs to be treated, since blockage of the bile ducts can cause the development of jaundice or cholecystitis.

Methods for diagnosing gallstones at Ichilov Hospital

To diagnose gallstones, Ichilov Hospital (Tel Aviv Sourasky Medical Center) performs an ultrasound (an examination using ultrasound). When difficulties arise in identifying stones, other research methods may be required at the discretion of doctors: nuclear magnetic resonance, endoscopic ultrasound, magnetic resonance imaging, endoscopic retrograde cholangiopancreatography.

Methods for the treatment of gallstone disease

The main method of treatment for gallstone disease is the removal of stones by laparoscopic surgery, during which visual control is carried out.