Gallstones l Gallbladder Disease

The gallbladder, a small, pear-shaped organ under the liver, collects and stores bile. Bile is a thick, greenish-yellow, bitter fluid made by the liver. Bile is made up of bile salts, electrolytes, bilirubin, cholesterol and other fats. The salts help stimulate the large intestine to secrete water and other slats, which helps move the contents of the digestive tract out of the body. Bilirubin is a waste product consisting of the remains of worn-out red blood cells. The breakdown products of drugs and wastes processed by the liver are also released in bile.

Bile helps the small intestine digest fats and remove waste products. It passes from the liver's bile duct into the duodenum, as needed. It does this through the common bile duct where the liver, gallbladder and pancreatic ducts join.

About half the bile secreted between meals flows into the small intestine. The other half is diverted from the common bile duct through the cystic duct, into the gallbladder where it is stored. Once there, nearly 90% of the water in the bile is absorbed by the bloodstream. What is left is a concentrated solution of bile salts, biliary lipids and sodium.

Gallstones are like tiny rocks that form in the gallbladder. They are made of cholesterol or bile particles that clump into a solid mass. A stone can grow as liver bile passes through the gallbladder. Most gallstones are small enough to pass out of the body through the intestines without our noticing. However, some do get caught in the narrow outlet of the gallbladder or in the intestines. This can lead to pain, a buildup of bile, pancreatitis and/or infection. Gallstones are common, especially in women, the elderly and overweight individuals.

Symptoms

Most gallstones don't cause symptoms for a long time. If they remain in the gallbladder, they may never cause symptoms. However, sometimes large stones can break down the wall of the gallbladder and get into the intestines causing a blockage. This is known as gallstone ileus.

Usually, the stones pass from the gallbladder into the bile ducts. They may remain there without blocking the flow of bile or causing symptoms, or they may pass on into the small intestine without being noticed.

However, if the gallstones cause a blockage in a bile duct, a person will have pain. The pain tends to come and go (this is sometimes called colic). Usually, the pain builds up to a certain level and then gradually falls. It can be sharp and intermittent for several hours.

Where the pain is felt can vary. Usually it is in the upper right part of the abdomen, which may be tender to touch. The pain may be felt in the right shoulder blade. A person may feel nauseated and throw up. If the blocked bile duct becomes infected, a person may develop a fever, chills and a yellowish cast to his or her skin.

Gallstones can block the cystic duct, causing the gallbladder to become inflamed (acute cholecystitis). Stones may block the pancreatic duct causing inflammation of the pancreas (pancreatitis).

Symptoms such as indigestion, an inability to tolerate fatty foods, belching, bloating, a feeling of fullness and nausea are some times believed to be gallstones. However, these symptoms are also common to indigestion or peptic ulcer disease. If a person feels pain in the right upper part of the abdomen after eating fatty food, this may be a sign of gallstones.

Causes and Risk Factors

High levels of estrogen, usually from multiple pregnancies or birth control pills (or both), are thought to be one cause of gallstones in women. Other factors that put a person at higher risk of developing gallstones are:

• Being overweight
• Age. About 20% of American older than 65 have gallstones, but most never experience problems
• A Western diet
• Genetics
• Being a Native American or Hispanic
• Having sickle cell anemia
• Crash dieting

Diagnosis

Patients having a gallstone attack report pain in the upper abdomen, usually on the right side, along with belching, gas, nausea and/or loss of appetite. In more serious cases, the patient may show signs of jaundice and have a fever.

Regular X-rays won't help the doctor find gallstones, but several other procedures can, including:

• Ultrasound and CT scans. If a stone is blocking the flow of liver bile, an ultrasound or CT scan can reveal swollen bile ducts. Blood tests might then be ordered to see if there is damage to the liver or pancreas.
• Endoscopic ultrasound. This procedure uses sound waves to produced a detailed image that can show developing gallstones and changes in the pancreatic or biliary duct system.
• Endoscopic retrograde cholangiopancreatography (ERCP). This minimally invasive technique can find and remove blockages in the gall bladder and bile ducts
• Cholecochoscopy. This is an ERCP procedure that uses a second scope to get better views of and access to the biliary ducts.

Screening and Prevention

There is no way to screen for the disease. But since obesity is so closely linked, maintaining a normal weight is an important, especially for women. Avoiding high-fat meals and "yo-yo" weight-loss diets are also good ideas. If your background places you at high risk, avoid taking birth control pills or estrogen.

Treatment

Gallstones are treated only when they cause a great deal of discomfort. In those cases, removing gallbladder is recommended. This may be done using:

• Traditional surgery (open cholecystectomy)
• Laparoscopy, a minimally invasive surgical technique that allows patients to recover more quickly and with less pain
• Endoscopic retrograde cholangiopancreatography (ERCP), a minimally invasive technique that can be used for both diagnostic and therapeutic purposes
• Intracorporeal electrohydraulic lithotripsy (EHL), which is used to break up gallstones that are large or difficult to remove through the bile duct.
• Drugs, which dissolve gall stones slowly over six or more months. This is used with people who can't tolerate surgery. Unfortunately, it's not always effective and new stones can form when the patient stops taking the medicine.

Overall, gallbladder surgery has proven to be highly effective. Most people don't miss the organ since, like the appendix, it's no longer essential. In rare cases, there may be diarrhea and abdominal pain afterward. This is easily addressed with time, healing and sometimes diet.

Additional Resource at Cedars-Sinai

• Pancreatic and Biliary Disease Center