Gallstones

Introduction

Gallstones are formed when bile contains too much cholesterol (abnormal bile composition). Most are made of cholesterol and bile pigments. Gallstones can be very small, almost like sand, or pea-sized. Occasionally, gallstones grow to larger pebble-size, and less commonly, you can have one large stone which fills the gall bladder. You may never know if you have gallstones as you may have no symptoms.

What are gallstones?

Your gall bladder is a small pear-shaped muscular sac under your liver. It stores the bile (sometimes called gall) produced by your liver. Bile - a greenish-brown liquid - helps with digestion (mainly of fats) in the small intestine.

Bile is released into the intestine through small tubes called bile ducts. These join together and form the main bile duct. The gallbladder contracts when we eat and empties the stored bile into the main bile duct. The bile passes along the duct into the small intestine.

There are two types of gallstones depending on bile content:

• Cholesterol stones
• Pigment stones (bilirubin)

What are the symptoms of gallstones?

In many cases gallstones stay in the gallbladder and cause no problems, but if they partially or completely block the flow of bile they may cause an attack of biliary colic.

The symptoms are severe pain in the upper abdomen and sometimes nausea and vomiting. The pain is usually most severe on the right-hand side, just below the ribs. The pain is caused by the gallbladder squeezing hard to dislodge the stone or stones.

The pain can last just a few minutes, but more commonly lasts several hours. This severe pain may only happen once in your life, or it may flare up from time to time. Sometimes less severe pains occur now and then, particularly after a fatty meal.

Complications of Gallstones

More seriously, gallstones may lead to infection. Cholecystitis is inflammation of the gallbladder - symptoms develop fast and include abdominal pain and fever. If the pain is acute you may need to go to hospital. 

Less common complications caused by gallstones are obstructive jaundice and acute pancreatitis (inflammation of the pancreas). Jaundice is caused when a gallstone gets stuck in a bile duct. The blockage causes bile to seep into the bloodstream. Your skin and the whites of your eyes go yellow and your urine will be dark and stools pale.

The main bile duct and the pancreatic duct join together before opening into the small intestine. The pancreatic duct carries a fluid rich in enzymes (chemicals that digest food). A gallstone could block both ducts and result in inflammation of the pancreas that causes abdominal pain (biliary colic). You may feel this just behind your ribs, spreading through to your back and experience nausea, vomiting and fever.

Am I at risk of developing gallstones?

It's not possible to predict precisely who will develop gallstones - though they do seem to run in families.

They are most common in women, especially those who are overweight and/or have been pregnant. They are also common in people who have recently lost weight. If you're on an oral contraceptive, or undergoing high-dose oestrogen therapy (sometimes used to treat osteoporosis and the menopause), you have a higher risk of developing gallstones.

In most cases, gallstones occur when your liver produces bile with high cholesterol content. An excess of cholesterol in your bile may be due to the following factors:

• a high-fat diet
• ageing
• eating too many refined dietary carbohydrates - (white bread, cakes, and low-fibre cereals)
• using oral contraceptives
• a genetic disorder where there is an excessive amount of cholesterol in the blood, such as hypercholesterolaemia
• liver disease that reduces the levels of bile salts

Less often, gallstones occur when there is too much bilirubin in your bile. Bilirubin is produced when your body breaks down old red blood cells.

People with the following conditions sometime develop this type of gallstone:

• cirrhosis (liver disease)
• infections in the bile duct
• sickle cell anaemia (an inherited blood disorder)

How will gallstones be diagnosed?

Your doctor may suspect gallstones because of the location of pain. You will need to have blood tests and an ultrasound scan. Sometimes an endoscopy procedure may be carried out. Gallstones are often found when the abdomen is scanned for other reasons. Even if gallstones are found, they may not be the cause of the problems being investigated.

What is the treatment for gallstones?

It is not always necessary to remove gallstones, if they cause few or no symptoms. The frequency and severity of biliary colic episodes and any complications will determine whether treatment is necessary.

Gallstones in the gallbladder are normally treated by surgically removing your gallbladder in a procedure known as a cholecystectomy. This can be carried out through keyhole surgery. You'll be in hospital for a few days and need a couple of weeks to recover.

For around 10 per cent of patients keyhole surgery is not possible, so an operation called an open cholecystectomy will be performed. This is where the gallbladder is removed through a large cut in your abdomen. The surgery often requires a longer stay in hospital and a rest period of about six weeks.

Most people who have had their gallbladder removed can continue to eat a normal diet. You may occasionally feel bloated or get indigestion - often after eating food with a high fat content. There may be an increase in the frequency of passing stools and this can be treated by anti-diarrhoeal medication.

Gallstones made of cholesterol can sometimes be dissolved using a medication, but this is slow-acting and not always effective.

Endoscopic retrograde cholangiopancreatography (ERCP) allows the removal of gallstones without removing your gallbladder. It is normally carried out under a local anaesthetic, which means that you will be awake but will not experience any pain.

An endoscope (a flexible fibre optic camera) is passed through your mouth, down through your digestive system and into your gallbladder. An electrically heated wire is passed through the endoscope and used to widen the opening to your bile duct to allow stones to be removed or pass naturally. This procedure can be carried out when surgery is not appropriate - for elderly and frail patients, for example.

Can gallstones be prevented?

Diet can be crucial in preventing gallstones. A low fat, high fibre diet is recommended including plenty of fresh fruit and vegetables and whole grains. But remember your body does need some cholesterol, so don't cut fat out altogether.

Being overweight increases the amount of cholesterol in your bile, and your chances of developing gallstones. You should therefore try and maintain a healthy weight by eating balanced diet and taking plenty of regular exercise. Some experts suggest a mainly vegetarian diet and cutting back on alcohol consumption can reduce the risk. 

Avoid low calorie, rapid weight loss diets as there is evidence to suggest that it disrupts your bile chemistry, increasing the chance of gallstones. Aim for gradual weight loss.

Clickthrough information and support link:

CORE - Digestive Disorders Foundation