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| Gallstones |
What are gallstones?
Gallstones form when liquid stored in the gallbladder hardens into pieces of
stone-like material. The liquid, called bile, is used to help the body digest
fats. Bile is made in the liver, then stored in the gallbladder until the body
needs to digest fat. At that time, the gallbladder contracts and pushes the
bile into a tube—called the common bile duct—that carries it to the small
intestine, where it helps with digestion.
Bile contains water, cholesterol, fats, bile salts, proteins, and bilirubin. Bile
salts break up fat, and bilirubin gives bile and stool a yellowish color. If the
liquid bile contains too much cholesterol, bile salts, or bilirubin, under certain
conditions it can harden into stones.
The two types of gallstones are cholesterol stones and pigment stones.
Cholesterol stones are usually yellow-green and are made primarily of
hardened cholesterol. They account for about 80 percent of gallstones.
Pigment stones are small, dark stones made of bilirubin. Gallstones can be
as small as a grain of sand or as large as a golf ball. The gallbladder can
develop just one large stone, hundreds of tiny stones, or almost any
combination.
Gallstones can block the normal flow of bile if they lodge in any of the ducts
that carry bile from the liver to the small intestine. That includes the hepatic
ducts, which carry bile out of the liver; the cystic duct, which takes bile to
and from the gallbladder; and the common bile duct, which takes bile from
the cystic and hepatic ducts to the small intestine. Bile trapped in these
ducts can cause inflammation in the gallbladder, the ducts, or, rarely, the
liver. Other ducts open into the common bile duct, including the pancreatic
duct, which carries digestive enzymes out of the pancreas. If a gallstone
blocks the opening to that duct, digestive enzymes can become trapped in
the pancreas and cause an extremely painful inflammation called gallstone
pancreatitis.
If any of these ducts remain blocked for a significant period of time, severe—
possibly fatal—damage or infections affecting the gallbladder, liver, or
pancreas can occur. Warning signs of a serious problem are fever, jaundice,
and persistent pain.
What causes gallstones?
Cholesterol Stones
Scientists believe cholesterol stones form when bile contains too much
cholesterol, too much bilirubin, or not enough bile salts, or when the
gallbladder does not empty as it should for some other reason.
Pigment Stones
The cause of pigment stones is uncertain. They tend to develop in people
who have cirrhosis, biliary tract infections, and hereditary blood disorders,
such as sickle cell anemia, in which too much bilirubin is formed.
Other Factors
It is believed that the mere presence of gallstones may cause more
gallstones to develop. However, other factors that contribute to gallstones
have been identified, especially for cholesterol stones.
Obesity. Obesity is a major risk factor for gallstones, especially in women.
A large clinical study showed that being even moderately overweight
increases the risk for developing gallstones. The most likely reason is that
obesity tends to reduce the amount of bile salts in bile, resulting in more
cholesterol. Obesity also decreases gallbladder emptying.
Estrogen. Excess estrogen from pregnancy, hormone replacement
therapy, or birth control pills appears to increase cholesterol levels in bile
and decrease gallbladder movement, both of which can lead to gallstones.
Ethnicity. Native Americans have a genetic predisposition to secrete high
levels of cholesterol in bile. In fact, they have the highest rate of gallstones
in the United States. A majority of Native American men have gallstones by
age 60. Among the Pima Indians of Arizona, 70 percent of women have
gallstones by age 30. Mexican American men and women of all ages also
have high rates of gallstones.
Gender. Women between 20 and 60 years of age are twice as likely to
develop gallstones as men.
Age. People over age 60 are more likely to develop gallstones than younger
people.
Cholesterol-lowering drugs. Drugs that lower cholesterol levels in blood
actually increase the amount of cholesterol secreted in bile. This in turn can
increase the risk of gallstones.
Diabetes. People with diabetes generally have high levels of fatty acids
called triglycerides. These fatty acids increase the risk of gallstones.
Rapid weight loss. As the body metabolizes fat during rapid weight loss, it
causes the liver to secrete extra cholesterol into bile, which can cause
gallstones.
Fasting. Fasting decreases gallbladder movement, causing the bile to
become overconcentrated with cholesterol, which can lead to gallstones.
What are the symptoms?
Symptoms of gallstones are often called a gallstone "attack" because they
occur suddenly. A typical attack can cause
* steady pain in the upper abdomen that increases rapidly and lasts from
30 minutes to several hours
* pain in the back between the shoulder blades
* pain under the right shoulder
* nausea or vomiting
Gallstone attacks often follow fatty meals, and they may occur during the
night. Other gallstone symptoms include
* abdominal bloating
* recurring intolerance of fatty foods
* colic
* belching
* gas
* indigestion
People who also have the above and any of following symptoms should see
a doctor right away:
* chills
* low-grade fever
* yellowish color of the skin or whites of the eyes
* clay-colored stools
Many people with gallstones have no symptoms. These patients are said to
be asymptomatic, and these stones are called "silent stones." They do not
interfere with gallbladder, liver, or pancreas function, and do not need
treatment.
How are gallstones diagnosed?
Many gallstones, especially silent stones, are discovered by accident during
tests for other problems. But when gallstones are suspected to be the
cause of symptoms, the doctor is likely to do an ultrasound exam.
Ultrasound uses sound waves to create images of organs. Sound waves are
sent toward the gallbladder through a handheld device that a technician
glides over the abdomen. The sound waves bounce off the gallbladder, liver,
and other organs such as a pregnant uterus, and their echoes make
electrical impulses that create a picture of the organ on a video monitor. If
stones are present, the sound waves will bounce off them, too, showing
their location. Ultrasound is the most sensitive and specific test for
gallstones.
Other tests may also be used.
* Computed tomography (CT) scan may show the gallstones or
complications.
* Magnetic resonance cholangiogram may diagnose blocked bile ducts.
* Cholescintigraphy (HIDA scan) is used to diagnose abnormal contraction
of the gallbladder or obstruction. The patient is injected with a radioactive
material that is taken up in the gallbladder, which is then stimulated to
contract.
* Endoscopic retrograde cholangiopancreatography (ERCP). The patient
swallows an endoscope—a long, flexible, lighted tube connected to a
computer and TV monitor. The doctor guides the endoscope through the
stomach and into the small intestine. The doctor then injects a special dye
that temporarily stains the ducts in the biliary system. ERCP is used to
locate and remove stones in the ducts.
* Blood tests. Blood tests may be used to look for signs of infection,
obstruction, pancreatitis, or jaundice.
Gallstone symptoms are similar to those of heart attack, appendicitis,
ulcers, irritable bowel syndrome, hiatal hernia, pancreatitis, and hepatitis. So
accurate diagnosis is important.
What is the treatment?
Surgery
Surgery to remove the gallbladder is the most common way to treat
symptomatic gallstones. (Asymptomatic gallstones usually do not need
treatment.) Each year more than 500,000 Americans have gallbladder
surgery. The surgery is called cholecystectomy.
The most common operation is called laparoscopic cholecystectomy. For
this operation, the surgeon makes several tiny incisions in the abdomen and
inserts surgical instruments and a miniature video camera into the
abdomen. The camera sends a magnified image from inside the body to a
video monitor, giving the surgeon a closeup view of the organs and tissues.
While watching the monitor, the surgeon uses the instruments to carefully
separate the gallbladder from the liver, ducts, and other structures. Then
the cystic duct is cut and the gallbladder removed through one of the small
incisions.
Because the abdominal muscles are not cut during laparoscopic surgery,
patients have less pain and fewer complications than they would have had
after surgery using a large incision across the abdomen. Recovery usually
involves only one night in the hospital, followed by several days of restricted
activity at home.
If the surgeon discovers any obstacles to the laparoscopic procedure, such
as infection or scarring from other operations, the operating team may have
to switch to open surgery. In some cases the obstacles are known before
surgery, and an open surgery is planned. It is called "open" surgery
because the surgeon has to make a 5- to 8-inch incision in the abdomen to
remove the gallbladder. This is a major surgery and may require about a 2-
to 7-day stay in the hospital and several more weeks at home to recover.
Open surgery is required in about 5 percent of gallbladder operations.
The most common complication in gallbladder surgery is injury to the bile
ducts. An injured common bile duct can leak bile and cause a painful and
potentially dangerous infection. Mild injuries can sometimes be treated
nonsurgically. Major injury, however, is more serious and requires additional
surgery.
If gallstones are in the bile ducts, the physician (usually a
gastroenterologist) may use endoscopic retrograde
cholangiopancreatography (ERCP) to locate and remove them before or
during the gallbladder surgery. In ERCP, the patient swallows an
endoscope—a long, flexible, lighted tube connected to a computer and TV
monitor. The doctor guides the endoscope through the stomach and into
the small intestine. The doctor then injects a special dye that temporarily
stains the ducts in the biliary system. Then the affected bile duct is located
and an instrument on the endoscope is used to cut the duct. The stone is
captured in a tiny basket and removed with the endoscope.
Occasionally, a person who has had a cholecystectomy is diagnosed with a
gallstone in the bile ducts weeks, months, or even years after the surgery.
The two-step ERCP procedure is usually successful in removing the stone.
Nonsurgical Treatment
Nonsurgical approaches are used only in special situations—such as when a
patient has a serious medical condition preventing surgery—and only for
cholesterol stones. Stones usually recur after nonsurgical treatment.
* Oral dissolution therapy. Drugs made from bile acid are used to
dissolve the stones. The drugs, ursodiol (Actigall) and chenodiol (Chenix),
work best for small cholesterol stones. Months or years of treatment may
be necessary before all the stones dissolve. Both drugs cause mild diarrhea,
and chenodiol may temporarily raise levels of blood cholesterol and the liver
enzyme transaminase.
* Contact dissolution therapy. This experimental procedure involves
injecting a drug directly into the gallbladder to dissolve stones. The drug—
methyl tertbutyl ether—can dissolve some stones in 1 to 3 days, but it
must be used very carefully because it is a flammable anesthetic that can be
toxic. The procedure is being tested in patients with symptomatic,
noncalcified cholesterol stones.
Content Source NIDDK.NIH
Gallstones form when liquid stored in the gallbladder hardens into pieces of
stone-like material. The liquid, called bile, is used to help the body digest
fats. Bile is made in the liver, then stored in the gallbladder until the body
needs to digest fat. At that time, the gallbladder contracts and pushes the
bile into a tube—called the common bile duct—that carries it to the small
intestine, where it helps with digestion.
Bile contains water, cholesterol, fats, bile salts, proteins, and bilirubin. Bile
salts break up fat, and bilirubin gives bile and stool a yellowish color. If the
liquid bile contains too much cholesterol, bile salts, or bilirubin, under certain
conditions it can harden into stones.
The two types of gallstones are cholesterol stones and pigment stones.
Cholesterol stones are usually yellow-green and are made primarily of
hardened cholesterol. They account for about 80 percent of gallstones.
Pigment stones are small, dark stones made of bilirubin. Gallstones can be
as small as a grain of sand or as large as a golf ball. The gallbladder can
develop just one large stone, hundreds of tiny stones, or almost any
combination.
Gallstones can block the normal flow of bile if they lodge in any of the ducts
that carry bile from the liver to the small intestine. That includes the hepatic
ducts, which carry bile out of the liver; the cystic duct, which takes bile to
and from the gallbladder; and the common bile duct, which takes bile from
the cystic and hepatic ducts to the small intestine. Bile trapped in these
ducts can cause inflammation in the gallbladder, the ducts, or, rarely, the
liver. Other ducts open into the common bile duct, including the pancreatic
duct, which carries digestive enzymes out of the pancreas. If a gallstone
blocks the opening to that duct, digestive enzymes can become trapped in
the pancreas and cause an extremely painful inflammation called gallstone
pancreatitis.
If any of these ducts remain blocked for a significant period of time, severe—
possibly fatal—damage or infections affecting the gallbladder, liver, or
pancreas can occur. Warning signs of a serious problem are fever, jaundice,
and persistent pain.
What causes gallstones?
Cholesterol Stones
Scientists believe cholesterol stones form when bile contains too much
cholesterol, too much bilirubin, or not enough bile salts, or when the
gallbladder does not empty as it should for some other reason.
Pigment Stones
The cause of pigment stones is uncertain. They tend to develop in people
who have cirrhosis, biliary tract infections, and hereditary blood disorders,
such as sickle cell anemia, in which too much bilirubin is formed.
Other Factors
It is believed that the mere presence of gallstones may cause more
gallstones to develop. However, other factors that contribute to gallstones
have been identified, especially for cholesterol stones.
Obesity. Obesity is a major risk factor for gallstones, especially in women.
A large clinical study showed that being even moderately overweight
increases the risk for developing gallstones. The most likely reason is that
obesity tends to reduce the amount of bile salts in bile, resulting in more
cholesterol. Obesity also decreases gallbladder emptying.
Estrogen. Excess estrogen from pregnancy, hormone replacement
therapy, or birth control pills appears to increase cholesterol levels in bile
and decrease gallbladder movement, both of which can lead to gallstones.
Ethnicity. Native Americans have a genetic predisposition to secrete high
levels of cholesterol in bile. In fact, they have the highest rate of gallstones
in the United States. A majority of Native American men have gallstones by
age 60. Among the Pima Indians of Arizona, 70 percent of women have
gallstones by age 30. Mexican American men and women of all ages also
have high rates of gallstones.
Gender. Women between 20 and 60 years of age are twice as likely to
develop gallstones as men.
Age. People over age 60 are more likely to develop gallstones than younger
people.
Cholesterol-lowering drugs. Drugs that lower cholesterol levels in blood
actually increase the amount of cholesterol secreted in bile. This in turn can
increase the risk of gallstones.
Diabetes. People with diabetes generally have high levels of fatty acids
called triglycerides. These fatty acids increase the risk of gallstones.
Rapid weight loss. As the body metabolizes fat during rapid weight loss, it
causes the liver to secrete extra cholesterol into bile, which can cause
gallstones.
Fasting. Fasting decreases gallbladder movement, causing the bile to
become overconcentrated with cholesterol, which can lead to gallstones.
What are the symptoms?
Symptoms of gallstones are often called a gallstone "attack" because they
occur suddenly. A typical attack can cause
* steady pain in the upper abdomen that increases rapidly and lasts from
30 minutes to several hours
* pain in the back between the shoulder blades
* pain under the right shoulder
* nausea or vomiting
Gallstone attacks often follow fatty meals, and they may occur during the
night. Other gallstone symptoms include
* abdominal bloating
* recurring intolerance of fatty foods
* colic
* belching
* gas
* indigestion
People who also have the above and any of following symptoms should see
a doctor right away:
* chills
* low-grade fever
* yellowish color of the skin or whites of the eyes
* clay-colored stools
Many people with gallstones have no symptoms. These patients are said to
be asymptomatic, and these stones are called "silent stones." They do not
interfere with gallbladder, liver, or pancreas function, and do not need
treatment.
How are gallstones diagnosed?
Many gallstones, especially silent stones, are discovered by accident during
tests for other problems. But when gallstones are suspected to be the
cause of symptoms, the doctor is likely to do an ultrasound exam.
Ultrasound uses sound waves to create images of organs. Sound waves are
sent toward the gallbladder through a handheld device that a technician
glides over the abdomen. The sound waves bounce off the gallbladder, liver,
and other organs such as a pregnant uterus, and their echoes make
electrical impulses that create a picture of the organ on a video monitor. If
stones are present, the sound waves will bounce off them, too, showing
their location. Ultrasound is the most sensitive and specific test for
gallstones.
Other tests may also be used.
* Computed tomography (CT) scan may show the gallstones or
complications.
* Magnetic resonance cholangiogram may diagnose blocked bile ducts.
* Cholescintigraphy (HIDA scan) is used to diagnose abnormal contraction
of the gallbladder or obstruction. The patient is injected with a radioactive
material that is taken up in the gallbladder, which is then stimulated to
contract.
* Endoscopic retrograde cholangiopancreatography (ERCP). The patient
swallows an endoscope—a long, flexible, lighted tube connected to a
computer and TV monitor. The doctor guides the endoscope through the
stomach and into the small intestine. The doctor then injects a special dye
that temporarily stains the ducts in the biliary system. ERCP is used to
locate and remove stones in the ducts.
* Blood tests. Blood tests may be used to look for signs of infection,
obstruction, pancreatitis, or jaundice.
Gallstone symptoms are similar to those of heart attack, appendicitis,
ulcers, irritable bowel syndrome, hiatal hernia, pancreatitis, and hepatitis. So
accurate diagnosis is important.
What is the treatment?
Surgery
Surgery to remove the gallbladder is the most common way to treat
symptomatic gallstones. (Asymptomatic gallstones usually do not need
treatment.) Each year more than 500,000 Americans have gallbladder
surgery. The surgery is called cholecystectomy.
The most common operation is called laparoscopic cholecystectomy. For
this operation, the surgeon makes several tiny incisions in the abdomen and
inserts surgical instruments and a miniature video camera into the
abdomen. The camera sends a magnified image from inside the body to a
video monitor, giving the surgeon a closeup view of the organs and tissues.
While watching the monitor, the surgeon uses the instruments to carefully
separate the gallbladder from the liver, ducts, and other structures. Then
the cystic duct is cut and the gallbladder removed through one of the small
incisions.
Because the abdominal muscles are not cut during laparoscopic surgery,
patients have less pain and fewer complications than they would have had
after surgery using a large incision across the abdomen. Recovery usually
involves only one night in the hospital, followed by several days of restricted
activity at home.
If the surgeon discovers any obstacles to the laparoscopic procedure, such
as infection or scarring from other operations, the operating team may have
to switch to open surgery. In some cases the obstacles are known before
surgery, and an open surgery is planned. It is called "open" surgery
because the surgeon has to make a 5- to 8-inch incision in the abdomen to
remove the gallbladder. This is a major surgery and may require about a 2-
to 7-day stay in the hospital and several more weeks at home to recover.
Open surgery is required in about 5 percent of gallbladder operations.
The most common complication in gallbladder surgery is injury to the bile
ducts. An injured common bile duct can leak bile and cause a painful and
potentially dangerous infection. Mild injuries can sometimes be treated
nonsurgically. Major injury, however, is more serious and requires additional
surgery.
If gallstones are in the bile ducts, the physician (usually a
gastroenterologist) may use endoscopic retrograde
cholangiopancreatography (ERCP) to locate and remove them before or
during the gallbladder surgery. In ERCP, the patient swallows an
endoscope—a long, flexible, lighted tube connected to a computer and TV
monitor. The doctor guides the endoscope through the stomach and into
the small intestine. The doctor then injects a special dye that temporarily
stains the ducts in the biliary system. Then the affected bile duct is located
and an instrument on the endoscope is used to cut the duct. The stone is
captured in a tiny basket and removed with the endoscope.
Occasionally, a person who has had a cholecystectomy is diagnosed with a
gallstone in the bile ducts weeks, months, or even years after the surgery.
The two-step ERCP procedure is usually successful in removing the stone.
Nonsurgical Treatment
Nonsurgical approaches are used only in special situations—such as when a
patient has a serious medical condition preventing surgery—and only for
cholesterol stones. Stones usually recur after nonsurgical treatment.
* Oral dissolution therapy. Drugs made from bile acid are used to
dissolve the stones. The drugs, ursodiol (Actigall) and chenodiol (Chenix),
work best for small cholesterol stones. Months or years of treatment may
be necessary before all the stones dissolve. Both drugs cause mild diarrhea,
and chenodiol may temporarily raise levels of blood cholesterol and the liver
enzyme transaminase.
* Contact dissolution therapy. This experimental procedure involves
injecting a drug directly into the gallbladder to dissolve stones. The drug—
methyl tertbutyl ether—can dissolve some stones in 1 to 3 days, but it
must be used very carefully because it is a flammable anesthetic that can be
toxic. The procedure is being tested in patients with symptomatic,
noncalcified cholesterol stones.
Content Source NIDDK.NIH
| MEDICAL NOTES |
DISEASES AND
CONDITIONS
Acidosis
Acne
Acromegaly
Addison's Disease
Adrenal Crisis
Age. macular degn
Alzheimer's disease
Autoimmune
Hepatitis
Barrett's Esophagus
Cancer
Constipation
Colon Polyps
Crohns Disease
Cushing's Syndrm.
Diabetes
Erectile Dysfunction
Fecal Incontinence
Gallstones
Gastritis
Gastroenteritis
Gastroesophageal
Reflux (GERD)
Growth Hormone
Def.
Heartburn
Hemochromatosis
Hemorrhoids
Hyperparathyroidism
Hypertension
Inflam. Bowel Dis.
Kidney Stone
Liver Cirrhosis
Migraines
Multiple Sclerosis
Obesity
Osteorithritis
Osteoporosis
Pancreatitis
Parkinson's Disease
Peyronies' Disease
Prolactinoma
Psoriasis
Sprain and Strain
Stroke
Ulcerative Colitis
Urin. Incontinence
Vitiligo
CONDITIONS
Acidosis
Acne
Acromegaly
Addison's Disease
Adrenal Crisis
Age. macular degn
Alzheimer's disease
Autoimmune
Hepatitis
Barrett's Esophagus
Cancer
Constipation
Colon Polyps
Crohns Disease
Cushing's Syndrm.
Diabetes
Erectile Dysfunction
Fecal Incontinence
Gallstones
Gastritis
Gastroenteritis
Gastroesophageal
Reflux (GERD)
Growth Hormone
Def.
Heartburn
Hemochromatosis
Hemorrhoids
Hyperparathyroidism
Hypertension
Inflam. Bowel Dis.
Kidney Stone
Liver Cirrhosis
Migraines
Multiple Sclerosis
Obesity
Osteorithritis
Osteoporosis
Pancreatitis
Parkinson's Disease
Peyronies' Disease
Prolactinoma
Psoriasis
Sprain and Strain
Stroke
Ulcerative Colitis
Urin. Incontinence
Vitiligo