Gallstones

Gallstones occur in up to 20% of American women by the age of 60. Women between the ages of 20 and 60 years are three times more likely to develop gallstones than men.

The gallbladder is a pouch that sits beside the liver and stores bile. Bile is a green-yellow fluid produced by the liver. After eating, the gallbladder releases bile into the intestines where it helps with digestion. Although the gallbladder helps with natural food digestion, people can live a normal life without it.

Gallstones are solid clumps of cholesterol crystals and other substances that may be of variable size.

How are gallstones formed?

Bile is composed of fatty substances, like cholesterol. When excessive amounts of fat are present, crystals form. Over time, these crystals can combine and form stones. The initial formation of these stones does not cause pain or symptoms.

Are all gallstones the same?

No. There are different types of gallstones, depending on which fatty substances of the bile has solidified. Also, the stones can vary in size, ranging from a single grain of sand up to the size of a ping-pong ball.

About 90% of gallstones are composed of cholesterol. The remainder consist of pigmented material (bilirubin). The reason for the formation of pigment stones is not yet fully understood. However, some people with blood disorders such as Sickle Cell Anemia or Thalassemia are at increased risk for developing pigmented stones.

What symptoms are associated with gallstones?

Most persons with gallstones (80%) have no symptoms of pain. These people are said to have "silent" gallstones.

Patients with symptomatic gallstones usually experience pain in the right upper region of the abdomen, but sometimes pain may localize to the right shoulder or chest. When the pain of a "gallbladder attack" lasts longer than 1 to 2 hours, or is associated with fever, you should see your doctor immediately.

Will everyone with silent gallstones eventually have a gallbladder attack?

No, the risk of silent gallstones causing a gallbladder attack is about 1% per year. In other words if 100 persons had silent gallstones, only ten would have a gallbladder attack after 10 years, and 90 would still have no symptoms.

What tests are needed to diagnose gallstones?

Since 80% of persons with gallstones have no symptoms, it is important to realize that tests for gallstones are only needed when symptoms are present. Your doctor will know which of the following tests would be best for you.

Abdominal Ultrasound: this is the safest, simplest and most readily available test to diagnose gallstones. Sonar waves from a probe are passed over the abdomen to visualize the gallbladder and detect the presence of stones. This test is not an x-ray and can be safely performed during pregnancy.

OCG (Oral Cholecystogram): this is an x-ray test. Iodine pills are given and an x-ray taken the following day. This test should not be performed during pregnancy.

CT Scan (computerized tomography): this test uses x-rays which are not safe during pregnancy. This test is not very accurate for diagnosing gallstones.

Nuclear Scan (HIDA, DISIDA): This test involves injection of a tiny amount of radioactive tracer into the blood, which quickly accumulates in the liver and gallbladder and can be seen with a special camera. This is a very accurate and safe test during an acute attack, but generally is not recommended during pregnancy.

ERCP (Endoscopic Retrograde Cholangiopancreatogram): This is a very important x-ray test that is used only in special cases. It is generally not done during pregnancy. Sometimes, the ERCP test is the only way to diagnose gallstones or stones that have migrated into the bile duct. This procedure may be used to remove gallstones that have migrated into the bile duct and sometimes avoid the need for surgery.

Infection of the bile ducts is called cholangitis. This is a very serious medical illness, characterized by abdominal pain, fever, yellowing of the eyes and skin (jaundice), and even infection in the blood stream. When cholangitis occurs, the ERCP test is usually done on an emergency basis to remove obstructing stones and drain the infection.

What are the treatment options?

Persons with symptomatic gallstones should usually undergo surgery to remove the gallbladder.

"Open" cholecystectomy: the classic traditional treatment for gallstones. This procedure requires an abdominal incision. The patient remains in the hospital for five to seven days.

"Laparoscopic" cholecystectomy: the newer and often preferred treatment, where the gallbladder is removed with a lighted tube (called a laparoscope) through a small incision in the abdomen. The surgeon views the entire procedure on a television monitor. Most patients leave the hospital after a few of days.

Dissolution of Gallstones: ursodeoxycholic acid, Actigal®, is a medicine that can be given as a pill to dissolve gallstones. Therapy requires at least 6 to 12 months and is successful in dissolving stones in 40-80% of cases. When surgery is too risky, the symptoms are mild, the stones are small, and rich in cholesterol, dissolution of gallstones is a reasonable alternative.