Gallstones

Gallstones - causes, symptoms, treatment
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Gallstones cause problems when they block any of the ducts carrying bile from the liver or gallbladder or digestive enzymes from the pancreas to the small intestine. It's the effect of female hormones. Estrogen increases cholesterol in the bile, and progesterone slows the emptying of the gallbladder. That may explain why the risk for women, relative to men, decreases with age. Before age 40, women are diagnosed with gallstones almost three times more often than men are pregnancy, for example, increases the risk , but by age 60, their risk is just slightly greater.

Estrogen therapy increases the risk, especially when taken as a pill rather than a patch. Oral contraceptive pills also increase the risk slightly, but only in the first decade of use. Obesity is another risk factor, because bodies with more fat produce more estrogen. Paradoxically, rapid weight loss also increases the risk, because very low-calorie diets interfere with bile production and therefore cause more crystallization of cholesterol. Gallstones are so common after weight-loss surgery that patients are often advised to have their gallbladders removed at the same time. Gallstones are also more likely to occur in people with diabetes or any condition that decreases gallbladder contractions or intestinal motility, such as a spinal cord injury.

Finally, there's some evidence for genetic vulnerability to gallstone formation. Most people who have gallstones don't know it. Their gallstones stay silent and may only be discovered incidentally, through an ultrasound or CT scan performed for other reasons. Symptoms arise mainly when stones pass through a bile duct or obstruct it, causing biliary colic — better known as a gallbladder attack. These attacks occur when the gallbladder contracts usually in response to a fatty meal and presses the stones so as to block the gallbladder duct.

What are gallstones?

The main symptom is pain, usually in the right upper or middle abdomen just below the rib cage , which builds to greatest intensity within an hour and can persist up to several hours. It can be either sharp and knifelike or a deep ache; sometimes it radiates to the back or the right shoulder. There may also be nausea and vomiting. The pain subsides as the gallbladder relaxes. A stone lodged in a duct can also cause more serious problems, including acute cholecystitis inflammation of the gallbladder , pancreatitis inflammation of the pancreas , or cholangitis inflammation of the bile ducts in the liver.

Any of these conditions can cause severe pain and other symptoms, including jaundice, high fever, chills, and vomiting. Treatment usually requires intravenous antibiotics and often surgical removal of the stone. If you think you're having a gallbladder attack, your clinician will probably order several blood tests and an abdominal ultrasound after you fast for at least eight hours.

Understanding Gallstones: Types, Pain, and More

Ultrasound is particularly helpful in diagnosing acute cholecystitis because it also picks up any thickening of the gallbladder wall and indicates the presence of fluid, which may suggest inflammation. Other diagnostic techniques include cholescintigraphy, a radioactive injection used to view a possible blockage of the cystic duct; magnetic resonance imaging MRI of the bile ducts; endoscopic ultrasonography, which introduces an ultrasound device through the mouth, esophagus, and stomach to the duodenum the first section of the small intestine to get images of the area; and endoscopic retrograde cholangiopancreatography, which uses a scope inserted through the mouth to the duodenum to view the biliary ducts.

Gallstones should be treated only if they cause symptoms. For recurrent gallbladder attacks, the most effective treatment is surgical removal of the gallbladder, or cholecystectomy.

In the past, the standard procedure was surgery requiring a five-inch incision and a hospital stay of up to a week. This approach has largely been replaced by laparoscopic cholecystectomy, in which the gallbladder is removed with instruments inserted through small incisions in the skin. This procedure requires only an overnight hospital stay and a week of recovery at home.

You can easily live without a gallbladder.

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The liver produces enough bile for normal digestion. Gallstones in the bile duct are sometimes seen during an ultrasound scan.

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A magnetic resonance imaging MRI scan may be carried out to look for gallstones in the bile ducts. This type of scan uses strong magnetic fields and radio waves to produce detailed images of the inside of the body.

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A procedure called a cholangiography can give further information about the condition of your gallbladder. A cholangiography uses a dye that shows up on X-rays. After the dye has been introduced, X-ray images are taken. They'll reveal any abnormality in your bile or pancreatic systems. If your gallbladder and bile systems are working normally, the dye will be absorbed in the places it's meant to go your liver, bile ducts, intestines and gallbladder.

This type of scan involves taking a series of X-rays from many different angles. If you don't have any symptoms, a policy of 'active monitoring' is often recommended.

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This means you won't receive immediate treatment, but you should let your GP know if you notice any symptoms. As a general rule, the longer you go without symptoms, the less likely it is that your condition will get worse.

If you have episodes of abdominal pain biliary colic , treatment depends on how the pain affects your daily activities. Some people may experience symptoms of bloating and diarrhoea after eating fatty or spicy food.

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If certain foods do trigger symptoms, you may wish to avoid them in the future. If surgery is recommended, you'll usually have keyhole surgery to remove your gallbladder. This is known as a laparoscopic cholecystectomy. One larger cut about cm will be by the belly button and the others each 1cm or less will be on the right side of your abdomen. Your abdomen is temporarily inflated using carbon dioxide gas.

This is harmless and makes it easier for the surgeon to see your organs. This allows your surgeon to view the operation on a video monitor. Your surgeon will then remove your gallbladder using special surgical instruments. If it's thought there may be gallstones in the bile duct, an X-ray or ultrasound scan of the bile duct is also taken during the operation. If gallstones are found, they may be removed during keyhole surgery. If the operation can't be done this way or an unexpected complication occurs, it may have to be converted to open surgery see below.

After the gallbladder has been removed, the gas in your abdomen escapes through the laparoscope and the cuts are closed with dissolvable stitches and covered with dressings. Full recovery typically takes around 10 days. Single-incision laparoscopic cholecystectomy is a newer type of keyhole surgery used to remove the gallbladder. Access to this type of surgery is also limited because it needs an experienced surgeon with specialist training.

In these circumstances, an open cholecystectomy may be recommended. During this procedure, a cm in incision is made in your abdomen underneath the ribs so the gallbladder can be removed. Open surgery is just as effective as laparoscopic surgery, but it does have a longer recovery time and causes more visible scarring.

An endoscopic retrograde cholangio-pancreatography ERCP is a procedure that can be used to remove gallstones from the bile duct. The gallbladder isn't removed during this procedure, so any stones in the gallbladder will remain unless removed using the surgical techniques mentioned above. ERCP is similar to a diagnostic cholangiography see diagnosing gallstones for more information , where an endoscope long, thin flexible tube with a camera at the end is passed through your mouth down to where the bile duct opens into the small intestine. The bile duct stones are then removed or left to pass into your intestine and out of your body.

Sometimes a small tube called a stent is permanently placed in the bile duct to help the bile and stones pass. An ERCP is usually carried out under sedation, which means you'll be awake throughout the procedure but won't experience any pain. You may need to stay overnight in hospital after the procedure so you can be monitored. Side effects of ursodeoxycholic acid are uncommon and are usually mild.

The most commonly reported side effects are feeling sick, being sick and itchy skin. The use of ursodeoxycholic acid isn't usually recommended for pregnant or breastfeeding women. Sexually active women should use either a barrier method of contraception, such as a condom, or a low-dose oestrogen contraceptive pill while taking ursodeoxycholic acid, as it may affect other types of oral contraceptive pills. Ursodeoxycholic acid tablets are occasionally also prescribed as a precaution against gallstones if it's thought you're at risk of developing them.

For example, you may be prescribed ursodeoxycholic acid if you've recently had weight loss surgery, as rapid weight loss can cause gallstones to grow.

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A small number of people with gallstones may develop serious problems if the gallstones cause a severe blockage or move into another part of the digestive system. In some cases of gallstone disease a bile duct can become permanently blocked, which can lead to a build-up of bile inside the gallbladder.

Types of gallstone

BMJ Best Practice. Jaundice sometimes called yellow jaundice : this is caused because the body is unable to get rid of bilirubin, which is a yellow chemical that occurs normally in the body. This allows your surgeon to view the operation on a video monitor. Pregnancy and Gallbladder: Is It Affected? Ethics declarations Competing interests The authors declare no competing interests.