Gallstones

• What is Gallstones
• Statistics on Gallstones
• Risk Factors for Gallstones
• Progression of Gallstones
• Symptoms of Gallstones
• Clinical Examination of Gallstones
• How is Gallstones Diagnosed?
• Prognosis of Gallstones
• How is Gallstones Treated?
• Gallstones References

What is Gallstones

Gallstone disease is a disease of the gall bladder. Gallstones are solid “stones” which are formed from concretions within the gallbladder.

They are two main types: Cholesterol stones (80%), and pigment stones (20%). Pigment stones are composed of bilirubin, the byproduct of haemoglobin (a component in red blood cells) breakdown.

Statistics on Gallstones

Gallstones are present in approxiamately 10-20% of the population. Gallstones may be present at any age but are unusual before the third decade. There is a progressive increase with age, and in patients over 50 the prevalence ranges between 25-30%.

The prevalence is two to three times higher in women than in men. The third National Health and Nutrition Examination Survey estimated that there are 6.3 million men and 14.2 million women aged 20 to 74 in the United States with gallbladder disease.

Risk Factors for Gallstones

Risk factors for cholesterol stones include:

• High serum cholesterol levels,
• Increased age,
• Female sex,
• Pregnancy,
• Multiparity,
• Obesity,
• Rapid weight loss,
• Contraceptive pill,
• Hormone replacement therapy,
• Ileal disease and resection,
• Diabetes mellitus,
• Liver cirrhosis,
• Gallbladder stasis,
• Decreased physical activity,
• Crohn’s disease and
• Total parenteral nutrition.

Risk factors for pigment stones include:

• Chronic hameolysis (red blood cell breakdown)
• Hereditary spherocytosis,
• Sickle cell disease, as well as
• Liver cirrhosis.

They may also form in the bile ducts after cholecystectomy (surgical removal of the gallbladder).

There are a few drugs that promote the formation of gallstones:

• Oestrogen
• Oral contraceptives
• Octreotide
• Clofibrate
• Ceftriaxone – this is a major cause of biliary sludge in hospitalised patients.

There are several protective factors against gallstone formation:

• Ascorbic acid
• Coffee
• Vegetable protein
• Poly- and mono-unsaturated fats

Progression of Gallstones

Gallstones are asymptomatic in most patients. They are usually an incidental finding on abdominal radiography. Around 2-4% of patients will experience biliary pain during the first 5 years and then this decreases to 1% per year after that.

After a first attack, as many as half of these patients will have recurrent episodes within 2 years of their first attack and thus elective surgical removal (cholecystectomy) of the gallbladder is recommended for symptomatic patients.

How is Gallstones Diagnosed?

Gallstones that does not cause symptoms cannot be detected by routine laboratory tests.

• An ultrasound: is the method of choice for identifying gallstones (also for gallstone complications).
• An x-ray of the tummy – only 10% of gallstones are visible on an x-ray, but this can be useful for excluding alternative diagnoses.

Various tests may be ordered should any complications be suspected (cholecystitis, cholangitis):

• Full blood count – elevated white cell count, ESR (a test for inflammation in the body) indicating inflammation
• Liver function tests – biliruibin, evidence of stasis (increased ALP), liver function.
• Blood cultures – required in the case of cholangitis.
• Coagulation profile – may be a clotting defect due to poor absorption of vitamin K.

Prognosis of Gallstones

As mentioned above, having one episode of biliary pain means the patient is likely to have futher episodes. However, biliary pain is not necessarily a warning of more complicated disease as the risk of developing complications in symptomatic patients is 1-2% per year and remains steady over time. These can be potentially serious complications and are prevented with a cholecystectomy provided no stones are left in the common bile duct.

How is Gallstones Treated?

For Biliary colic itself – pain relief is all that is required acutely, as well as assessment for complications and to exclude other more serious diagnoses. Sometimes antibiotics are given if infection is suspected.

Cholecystectomy – surgical removal of the gallbladder (usually elective at a later date) is recommended for symptomatic patients. This can be done preferably as a laparoscopic procedure (or known as keyhole surgery) as it has a quicker recovery time and shorter stay in hospital. Cholecystectomy will need to be performed earlier in patients who present with gallbladder inflammation to prevent more serious complications.

For those not suitable for surgery or refuse surgery there are also other options to dissolve or shatter the stones without the need for an operation – although not necessarily as successful as surgery. These include:

• Dissolution: using acid treatments to dissolve the stones
• Shock wave therapy: using shock waves to obliterate the stones

Gallstones References

1. Braunwald, Fauci, Kasper, Hauser, Longo, Jameson. Harrison’s Principles of Internal Medicine. 15th Edition. McGraw-Hill. 2001.
2. Cotran, Kumar, Collins 6th edition. Robbins Pathologic Basis of Disease. WB Saunders Company. 1999.
3. Haslet C, Chiliers ER, Boon NA, Colledge NR. Principles and Practice of Medicine. Churchill Livingstone 2002.
4. Kumar P, Clark M. CLINICAL MEDICINE. WB Saunders 2002.
5. Up to Date: Clinical features and diagnosis of acute cholecystitis [online]. 2005. [Cited 2005 September 28th]. Available from: URL: http://www.utdol.com/application/topic.asp?file=biliaryt/6853&type=A&selectedTitle=2~81
6. Up To Date: Epidemiology of and risk factors for gallstones [online]. 2005. [Cited 2005 September 28th]. Available from: URL: http://www.utdol.com/application/topic/print.asp? file=biliaryt/5497&type=A&selectedTitle=3~81
7. Up to Date: Nonsurgical treatment of gallstone disease [online]. 2005. [Cited 2005 September 28th]. Available from: URL: http://www.utdol.com/application/topic.asp?file=biliaryt/7894&type=A&selectedTitle=7~81
8. Up to Date: Treatment of acute cholecystitis [online]. 2005. [Cited 2005 September 28th]. Available from: URL: http://www.utdol.com/application/topic.asp?file=biliaryt/8379&type=A&selectedTitle=9~81