Gallbladder
The gallbladder is a small sac that is located below the liver. It stores bile that is produced in the liver. In the gallbladder water is extracted resulting in thick concentrated bile. Bile helps in the breakdown of dietary fats. In a fasting state, the gallbladder fills with bile and gets concentrated. Presence of food results in signal being sent to the gallbladder which squeezes the bile out of the gallbladder into the bowel to help in the digestion of food. The signal is the strongest with fatty food and some spicy foods. This is the reason why gallbladder pain is worse with fatty foods.
Gallstones
Bile in the gallbladder is made up of water, cholesterol, proteins, bile salts and bilirubin (a waste product produced in the liver). These constituents are in solution in a healthy state. However, when there is an imbalance in these constituents with too much fat or bilirubin, too little bile salts or a gallbladder that does not empty very well then it is no longer in solution and they crystallise into stones. Gallstones can be fine similar to grains of sand to large stones over 3 cms in size.
The types of stones are:
Cholesterol stones- These are composed of cholesterol and are yellow in colour. They can be large in size. Pure cholesterol stones account for approximately 10% of gallstones.
Pigment stones- these are dark brown or black stones when they contain too much bilirubin. These are usually small and numerous. They account for approximately 10% of gallstones
Mixed stones- These are the most common stones containing both cholesterol and bilirubin and account for 80% of all gallstones.
The types of stones are:
Cholesterol stones- These are composed of cholesterol and are yellow in colour. They can be large in size. Pure cholesterol stones account for approximately 10% of gallstones.
Pigment stones- these are dark brown or black stones when they contain too much bilirubin. These are usually small and numerous. They account for approximately 10% of gallstones
Mixed stones- These are the most common stones containing both cholesterol and bilirubin and account for 80% of all gallstones.
How common are gallstones?
Gallstones are more common in women and increases with increasing age. At age 30 years, 5% of women and 2% of men have or have had gallstones. The proportion rises at age 55 years to 20% in women and 10% in men and by the age 70 years it goes up to 30% in women and 20% in men. However, the majority of patients (80%) are asymptomatic and do not usually require any treatment. The risk of developing symptoms is about 2-3% per year. Once symptoms develop then treatment is often recommended.
Risk Factor
- Female
- Increasing age
- Obesity
- Pregnancy
- Medications such as Oral contraceptive pills or Hormone replacement therapy
- Family history
- Diabetes
- Rapid weight loss such as after bariatric surgery
- Liver disease
- Inflammatory bowel disease
- Blood disorders, such as sickle cell anaemia or leukaemia
Symptoms of gallstone
In the majority of patients, gallstones cause no symptoms. In the rest the symptoms of gallstones may include:
Biliary colic
Biliary colic is the pain caused by gallstones. The pain occurs in the upper part of the abdomen and often the pain goes around to the back or the right shoulder. The pain can be associated with nausea and vomiting. It is often triggered by fatty foods and usually lasts a few hours. This is caused by stone blocking the opening of the gallbladder at the cystic duct.
Biliary colic
Biliary colic is the pain caused by gallstones. The pain occurs in the upper part of the abdomen and often the pain goes around to the back or the right shoulder. The pain can be associated with nausea and vomiting. It is often triggered by fatty foods and usually lasts a few hours. This is caused by stone blocking the opening of the gallbladder at the cystic duct.
Complications of gallstones
Acute cholecystitis
When biliary colic is associated with inflammation then it is called cholecystitis. The pain unlike biliary colic lasts longer and can be more severe. There can be associated fever and nausea and vomiting. This is caused by a stone blocking the opening of the gallbladder but is more complete and persistent.
Acute cholecystitis is a serious medical condition requiring presentation to the emergency department for management including antibiotics and surgery.
Jaundice
Sometimes the stone blocking the gallbladder makes its way out of the gallbladder and blocks the main tube (bile duct) that connects the liver to the bowel (Choledocholithiasis). This causes back up of bile in the liver making the patient go yellow (jaundice). If there is an infection associated with this then it is called cholangitis. Patients with cholangitis have jaundice, pain and fever. This can be a life threatening emergency and requires presentation to hospital for urgent management.
Pancreatitis
Pancreatitis is inflammation of the pancreas. When the stone that is in the main bile duct gets stuck at the bottom end before it opens into the bowel it can cause pancreatitis. This is associated with severe pain, nausea and vomiting. It is also an emergency and requires presentation to the hospital.
When biliary colic is associated with inflammation then it is called cholecystitis. The pain unlike biliary colic lasts longer and can be more severe. There can be associated fever and nausea and vomiting. This is caused by a stone blocking the opening of the gallbladder but is more complete and persistent.
Acute cholecystitis is a serious medical condition requiring presentation to the emergency department for management including antibiotics and surgery.
Jaundice
Sometimes the stone blocking the gallbladder makes its way out of the gallbladder and blocks the main tube (bile duct) that connects the liver to the bowel (Choledocholithiasis). This causes back up of bile in the liver making the patient go yellow (jaundice). If there is an infection associated with this then it is called cholangitis. Patients with cholangitis have jaundice, pain and fever. This can be a life threatening emergency and requires presentation to hospital for urgent management.
Pancreatitis
Pancreatitis is inflammation of the pancreas. When the stone that is in the main bile duct gets stuck at the bottom end before it opens into the bowel it can cause pancreatitis. This is associated with severe pain, nausea and vomiting. It is also an emergency and requires presentation to the hospital.
Diagnosis
The diagnosis of gallstones is made on an abdominal ultrasound. This is the simplest and the most useful test to identify gallstones and to look for any complications related to the gallstone disease.
Sometimes, a CT scan of the abdomen is needed in some patients when the ultrasound is unable to see the gallbladder or to rule out other causes of abdominal pain.
Hepatobiliary iminodiacetic acid (HIDA) scan – a special type of nuclear scan that assesses how well the gallbladder functions. This is done in some patients who have symptoms that are suggestive of gallbladder pain but the ultrasound and CT scans are normal.
Magnetic resonance cholangiopancreatography (MRCP) – a type of MRI used to diagnose a stone that may have spilled out of the gallbladder.
Blood tests including liver function tests
Endoscopic retrograde cholangiopancreatography (ERCP). A type of endoscopy to treat gallstones that have come out of the gallbladder and move into the bile duct causing jaundice.
Sometimes, a CT scan of the abdomen is needed in some patients when the ultrasound is unable to see the gallbladder or to rule out other causes of abdominal pain.
Hepatobiliary iminodiacetic acid (HIDA) scan – a special type of nuclear scan that assesses how well the gallbladder functions. This is done in some patients who have symptoms that are suggestive of gallbladder pain but the ultrasound and CT scans are normal.
Magnetic resonance cholangiopancreatography (MRCP) – a type of MRI used to diagnose a stone that may have spilled out of the gallbladder.
Blood tests including liver function tests
Endoscopic retrograde cholangiopancreatography (ERCP). A type of endoscopy to treat gallstones that have come out of the gallbladder and move into the bile duct causing jaundice.
Management of gallstones
Patients with no symptoms related to the gallbladder can be managed without surgery. However, a small group of patients without symptoms may benefit from elective surgery if they have some high risk medical problems. Please discuss this with your general practitioner or the surgeon.
Dietary modifications with avoidance of fatty foods may prevent biliary colic.
Surgery
Surgery is the treatment of choice for symptomatic gallstones. It is one of the commonest surgical operations done in the elective and emergency setting.
Dietary modifications with avoidance of fatty foods may prevent biliary colic.
Surgery
Surgery is the treatment of choice for symptomatic gallstones. It is one of the commonest surgical operations done in the elective and emergency setting.
Frequently asked questions
Medications to dissolve gallstones
Cholesterol stones can be dissolved with oral medications. However, it may take 6-12 months to dissolve the stones with a high recurrence rate of stones forming again once medication is stopped. As a result this is not a common treatment and not recommended.
Lithotripsy
A machine that generates sound waves that shatter stones. This is often used in kidney stones. They are used patients with few small soft stones. However, this is not a recommended treatment option for gallstones and not used routinely. It may be available in some centres within a clinical trial.
Cholesterol stones can be dissolved with oral medications. However, it may take 6-12 months to dissolve the stones with a high recurrence rate of stones forming again once medication is stopped. As a result this is not a common treatment and not recommended.
Lithotripsy
A machine that generates sound waves that shatter stones. This is often used in kidney stones. They are used patients with few small soft stones. However, this is not a recommended treatment option for gallstones and not used routinely. It may be available in some centres within a clinical trial.
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