What are the other Names for this Condition? (Also known as/Synonyms)

• Cholelithiasis
• Gallbladder Stones
• Stones in the Gallbladder

What is Gallstones? (Definition/Background Information)

• Gallstones are marble-like deposits that form in the gallbladder, due to changes in the concentration of various components of bile. Bile is a fluid that is made by the liver and stored in the gallbladder
• Gallstones are classified on the basis of their constituent material (what they are composed of). Most commonly these Gallbladder Stones are composed of cholesterol and less commonly are composed of a component of blood called bilirubin
• The size of these stones can vary from that of a ‘peanut’ to the size of a ‘golf ball’. Majority of the times, Gallstones are found as an incidental finding, when they are not causing any symptoms
• The symptoms arise when they obstruct the duct of the gallbladder and prevent the gallbladder from draining its fluid into the intestine. The common signs and symptoms of include intermittent pain in the right upper side of abdomen, aggravation of pain by fatty meals, nausea, and vomiting. An ultrasound of abdomen is the diagnostic test of choice
• Removal of the gallbladder by surgery is the most effective treatment for Gallstones. Once the surgery is performed, the chances of developing the condition is practically nil

Who gets Gallstones? (Age and Sex Distribution)

• Women are more commonly affected by Gallstones than men, almost in the ratio of 2:1
• The affected age group may vary from early 30s to late 50s. The chances of developing Gallstones increase with age
• Gallstones are less commonly seen in the people of Africa and Asia, but are more common the western world, in North and South America

What are the Risk Factors for Gallstones? (Predisposing Factors)

Risk factors associated with Gallstones include:

• Female gender
• Advancing age: The older the age, the higher is the chance of developing Gallstones
• Obese and overweight individuals
• Pregnancy is a known condition to be associated with the development of Gallbladder Stones
• Decreased motility of gallbladder: This occurs in individuals who are on intravenous nutrition for a long period of time
• Individuals who regularly eat a diet high in fat and cholesterol, but low in fiber
• The risk increases if family members are affected
• Post-menopausal women taking hormone replacement
• Certain conditions affecting the liver can also lead to the development of Gallstones. Conditions, such as liver cirrhosis and infections of the biliary tract, are associated with Gallstone formation
• Individuals affected by chronic blood disorders, such as sickle cell anemia and thalassemia, are at an increased risk of developing bilirubin-type of Gallstones
• Those who undergo fat reduction surgeries and those who lose weight very rapidly, while being on a low-calorie diet, also have a greater risk

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases ones chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider. 

What are the Causes of Gallstones? (Etiology)

The exact cause of Gallstone formation is not clear. However, the following factors are known to contribute to their formation:

• Presence of excess cholesterol in the bile which may precipitate, leading to Gallstone formation
• Presence of excess bilirubin in the bile, which may occur with certain blood disorders and infections of the biliary tract
• Improper emptying of the Gallbladder may cause the bile to become concentrated, resulting in stone formation

Gallstones are broadly classified on the basis of their composition. They can be of the following types:

• Cholesterol stones: These are composed of cholesterol, protein component, and may contain small amounts of calcium and bile pigment. They are the most common types of stones that are present in almost 80% of the patients. The cholesterol level of blood does not affect the development of these stone types
• Pigment stones: They are seen in up to 20% of the cases presenting with gallbladder disease/condition. The majority of patients have underlying blood disorders that lead to the formation of pigmented Gallstones. The major component of these stone types is bilirubin
• Mixed type: It is the least common variety of Gallstone. They can contain varied concentration of cholesterol, calcium, bilirubin, and other components

What are the Signs and Symptoms of Gallstones?

Most of the individuals with Gallstones are asymptomatic.

• The symptoms may develop when a stone is large enough to block the duct draining the bile from the gallbladder to the first part of small intestine, duodenum
• This leads to increased efforts of the gallbladder to push the bile out, which thus presents as a cramping type of pain in the right upper abdomen
• This initial pattern presents as intermittent pain that subsides by itself. When it is complicated by some infection or other complication, it presents as continuous pain

The common signs and symptoms of Gallbladder Stones include:

• Abdominal pain
  • The pain is located in the right upper part of the belly and may radiate to the right shoulder
  • The type of pain may vary from being sharp, dull, or cramping in nature
  • It may be constant or intermittent
  • The pain is typically aggravated by fatty diet
• Fever and chills:
  • When there is an infection of the gallbladder, the patients may present with fever and chills
  • There may also be associated nausea and vomiting

How are Gallstones Diagnosed?

The diagnosis of Gallstones may involve the following tests and exams:

• A complete evaluation of medical history along with a thorough physical exam
• Various modalities of imaging are available to visualize the Gallstones, and these include:
  • Abdominal X-ray: It can only detect up to 10% of the Gallstones, which have high content of calcium and are thus seen on X-ray
  • Abdominal ultrasound: It is a test that uses high-frequency sound waves to detect the presence of Stones in the Gallbladder. It is the test of choice, when a patient presents with symptoms of Gallstones. This test may detect the presence of Gallstones in as many as 80% of the cases
  • HIDA scan: If an abdominal ultrasound does not detect the stones, but the clinical probability is high, then HIDA scans are generally used to confirm their presence. In this test, a dye is injected into the body and the movement of dye is followed through a series of images. This test has a high rate of detection of stones that are not seen on the ultrasound

Other less commonly used modalities in the detection of Gallstones include:

• CT scan of abdomen: It is a high-resolution scan of the abdomen, which gives better images of the abdomen. It is mainly used for detecting the complications associated with Gallstones, if any
• Cholangiography: It is a form of test that enables a direct visualization of the bile system. It can be performed by two methods:
  • Endoscopic retrograde cholangiopancreatography (ERCP: It is form of invasive test that serves the dual purpose of diagnosis and treatment
  • Magnetic resonance cholangiopancreatography (MRCP): It is a non-invasive form of test that is excellent to visualise the presence of stones in the biliary system. It is performed in patients who are poor candidates for ERCP

Blood tests to access the liver functions include:

• Liver function tests:
  • Bilirubin level
  • Liver enzymes, which include aminotransferase and alkaline phosphatase
• To assess the pancreatic function levels, enzymes secreted by the pancreas are measured that include:
  • Amylase
  • Lipase
• To assess the blood abnormalities:
  • Complete blood count
  • Coagulation studies
  • Studies to assess hereditary disorders may also be ordered

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis. 

What are the possible Complications of Gallstones?

The complications from Gallstones typically arise when they obstruct the ducts in the biliary system, or when they are associated with infections.

• Infectious complications:
  • Acute cholecystitis: It occurs when Gallstones block the bile duct and infection occurs in the gallbladder. It is a form of surgical emergency, as the infection is fatal, if timely treatment is not provided
  • Cholangitis: It occurs when the stone leaves the gallbladder and gets stuck in the distal bile duct, and infection of the bile duct taking place. This infection may spread to the liver and can be fatal
• Complications to obstruction in the biliary system:
  • Choledocholithiasis: When the stone reaches the common bile duct and gets stuck, it results in the obstruction of common bile duct, which may present as jaundice
  • Pancreatitis: It occurs when there is a blockage in the pancreatic ducts. The blockage is typically caused by a stone that leaves the gallbladder and enters the pancreatic system
  • Chronic cholecystitis: With repeated episodes of unresolved acute cholecystitis, a chronic form of the disease may develop. It is associated with decreased functioning of the gallbladder
• Gallbladder cancer: There is a very small risk of cancer in the gallbladder due to Gallstones, but it is very rare

How are Gallstones Treated?

Only symptomatic patients need treatment for Gallstones. Since most of the asymptomatic Gallstones would not progress to become symptomatic, they may be only monitored.

• The option to treat symptomatic Gallstones depends on the acuity of presentation
• Surgery is the first line of treatment
• If a patient is a poor candidate for surgery, medical management may be undertaken

A surgical removal of the gallbladder is the treatment of choice. This can be achieved in two ways:

• Laparoscopic removal (laparoscopic cholecystectomy) is the procedure of choice
  • It offers faster recovery
  • Less pain
  • Less complications
• Open cholecystectomy, which is rarely performed nowadays, for it involves
  • Bigger incisions
  • More pain
  • Longer hospitalization period

Medical management:

• It is reserved for the patients who cannot tolerate surgery
• Medications, such as chenodeoxycholic acid or ursodeoxycholic acid, may be given to dissolve the stones
• They take a long time to act and have inconsistent effects

Lithotripsy:

• For patients who are poor candidates of surgery and who do not respond to medical management
• It is associated with a high recurrence rate

How can Gallstones be Prevented?

Prevention of risk factors may be helpful in reducing the risk of Gallstones.

• Having a healthy diet and proper exercise routine can reduce the chances of developing risk factors for this condition
• Individuals who want to lose weight should do so progressively slowly and should not lose a considerable amount of weight within a short period of time

What is the Prognosis of Gallstones? (Outcomes/Resolutions)

• Gallstones may be best treated through a surgery
• Once the surgery is done the chances of developing the condition again is practically nil

Additional and Relevant Useful Information for Gallstones:

• The most common indication for performing a laparoscopic cholecystectomy is symptomatic gallstones causing pain (biliary colic)

The following article link will help you understand laparoscopic cholecystectomy surgical procedure:

http://www.dovemed.com/common-procedures/procedures-surgical/gallbladder-removal-by-laparoscopy-laparoscopic-cholecystectomy/