Gallstones - All You Need to Know

What Is the Function of Bile?

About 1500 ml of bile is secreted by the liver every day. Typically, bile is necessary for digesting fat and absorption of fat-soluble vitamins. It is also a medium through which waste products of metabolism, like bile pigments, cholesterol, drugs, etc., are excreted through the body. Bile salts and lecithin (phospholipids) keep the insoluble components of bile in a solution or an emulsion. Bile salts and lecithin are mainly responsible for emulsification.

What Are Gallstones?

Whenever there is an imbalance of these, the pigments and cholesterol can precipitate and form stones. Gallstones are a commonly occurring condition that forms in the gallbladder due to an imbalance in the composition of bile.

Gallstones are generally composed of cholesterol, bile pigments, and mucin. Gallstones can be asymptomatic and incidentally detected on an ultrasound scan. They can cause pain (biliary colic), acute calculous cholecystitis, chronic cholecystitis, acute pancreatitis (a severe condition), common bile duct obstruction, obstructive jaundice, and cholangitis (can be severe and cause multiple organ failures).

What Are the Types of Gallstones?

Gallstones are of two types, namely,

• Cholesterol Gallstones: These are the most widely prevalent gallstones, mainly composed of undissolved cholesterol. However, it may also contain specific other components. Due to their composition, these appear yellow.

• Pigment Gallstones: When there is an increased amount of bilirubin in the bile, these types of gallstones form. The bilirubin content gives these gallstones a dark brown to black color.

What Causes Gallstones?

There is no clear evidence to support the cause of gallstones. It has been attributed that gallstones occur due to:

• Excessive Cholesterol:

The cholesterol secreted by your liver is dissolved by the chemicals present in the bile. But, when there is more cholesterol than what the bile could actually dissolve, it results in the formation of gallstones.

• Excessive Bilirubin:

Chronic conditions like blood disorders, infections of the biliary tract, and liver cirrhosis result in an increased production of bilirubin, which is a by-product formed by the breakdown of red blood cells. Excessive production of bilirubin causes gallstone formation.

• Improper Excretion:

When the bile juice that is secreted cannot be excreted properly or is not excreted at all, it might lease to gallstone formation.

What Are the Symptoms of Gallstones?

• Asymptomatic: The majority of the gallstones remain asymptomatic and are incidentally detected on a routine ultrasound scan performed for unrelated symptoms. Asymptomatic stones need no treatment.

• Biliary Colic: Intermittent pain in the right upper abdomen, especially after taking food. This pain is referred to the right shoulder or the right scapular region, and it lasts only for a short interval. Biliary colic can be associated with nausea and vomiting. This pain warrants cholecystectomy, which means removal of the gallbladder.

• Acute Calculous Cholecystitis: This is caused when a stone is stuck in the cystic duct and infection supervenes. The pain starts suddenly in the right upper abdomen like in biliary colic and persists longer than in biliary colic, and it is not relieved unless treated. The pain can be very severe and associated with nausea, vomiting, fever, etc. Acute calculous cholecystitis needs treatment with antibiotics and analgesics. An attack of acute calculous cholecystitis is best treated with cholecystectomy in the same sitting. This condition does respond to antibiotics, but it tends to recur, often with complications. Hence, an attack of acute cholecystitis needs cholecystectomy in the same admission or an interval cholecystectomy after 4 to 6 weeks. Also, acute calculus can sometimes be complicated and can cause empyema (pus formation in the gallbladder) or perforation (the gallbladder wall can perforate and cause peritonitis, which can be life-threatening, warranting an emergency surgery).

• Acute Pancreatitis: Gallstones can slip into the bile duct and the intestine through the papilla of Vater. This can incite acute pancreatitis. Gallstones are the commonest cause of acute pancreatitis after alcohol. Acute pancreatitis can be severe and life-threatening by causing multiple organ failures, pancreatic necrosis, and sequelae. Cholecystectomy is recommended in the same admission or after the patient becomes fit to prevent another pancreatitis attack, which many a time recurs with a vengeance.

• Choledocholithiasis (Bile Duct Stones): The gallstones can slip into the bile duct and cause biliary obstruction and jaundice. Also, they can present with cholangitis (infection in the bile with bile duct obstruction, which causes bloodstream infection) when the patient has fever, chills, and can be severe enough to cause renal failure, coma, etc. This needs to be treated urgently with broad-spectrum intravenous antibiotics, which, if left untreated, leads to decompression of the biliary tract, most commonly by an endoscopic procedure called ERCP (endoscopic retrograde cholangiopancreatography).

What Increases the Risk of Gallstone Formation?

Risk factors for gallstone formation are of two types namely,

• Uncontrollable risk factors.

• Controllable risk factors.

Uncontrollable Risk Factors:

• Female sex.

• Having a family history of gallstone.

• Belonging to the native American or Mexican race.

• Older adults above the age of 12 years.

Controllable Risk Factors:

• Individuals who have undergone rapid weight loss.

• Obesity.

• Increased consumption of fatty foods.

• Less intake of fibers.

• Individuals with Type-2 diabetes mellitus.

• Liver cirrhosis.

• Pregnancy.

• Individuals taking oral contraceptive pills that contain increased estrogen.

• Hyperlipidemic drugs.

How Are Gallstones Diagnosed?

1. Physical Examination:

Yellowish discoloration of the skin and eyes is examined physically by the health care provider.

2. Ultrasound Scan:

Ultrasound helps produce images of your abdomen and is the most preferred test for diagnosing gallstones. It also helps in the diagnosis of acute cholecystitis.

3. CT Scan of the Abdomen:

It is also an imaging test that helps diagnose by visualizing the abdominal region.

4. Gallbladder Radionuclide Scan:

Radioactive material is injected intravenously to enter the gall bladder and liver in this test. Any blockage in the bile ducts can be determined with the help of this test.

5. Blood tests:

The amount of bilirubin in the bloodstream can be diagnosed by blood tests.

How Can We Treat Gallstones?

Surgical Treatment:

• Cholecystectomy: Cholecystectomy is the treatment of choice for symptomatic gallstones. It is of two types, namely open cholecystectomy and laparoscopic cholecystectomy. Laparoscopic cholecystectomy is a minimally invasive approach and is now the most common laparoscopic operation performed globally. It can also be performed as a day-case (admission and discharge on the same day) procedure. The recovery with laparoscopy is fast, and the patient can walk out of the hospital on the same day or the next.

Medical Treatment:

• Oral Dissolution Therapy: UDCA (Ursodeoxycholic Acid): It helps in the dissolution of cholesterol gallstones. This is not recommended, as the gallstone dissolution rate is low, and stones recur when the drug is stopped. Also, the cost of UDCA will be very high with no benefits.

• Percutaneous Gallbladder Drainage: In this procedure, a sterile needle is inserted into the gall bladder, and the bile is aspirated. It is only suggested in people where other treatment procedures are not possible.

• Shock Wave Lithotripsy: During this procedure, a lithotripter is used, which generates shock waves to break the gallstones.

How Can We Prevent the Formation of Gallstones?

The following dietary and lifestyle modifications help in either preventing the formation of gallstones or worsening of an existing gallstone:

• Do not skip meals and try taking your food correctly at mealtime.

• Intake of fiber-rich foods.

• When you are trying to lose weight, do it slowly. Rapid loss of weight can also lead to the formation of gallstones.

• Try maintaining an ideal body weight.

• Reduced the intake of refined carbohydrates.

• Drink an adequate amount of water.

• Stick to healthy saturated fats like olive oil or fish oil and avoid unsaturated fats.

• Exercise regularly.

Conclusion:

Gallstones do not require treatment when they appear asymptomatic. But when there is a yellowish discoloration of skin or eyes, it is essential to contact your health care provider at the earliest. If you have a family history of gallstone formation or if you belong to the female sex, you must take the necessary preventive measures to avoid the occurence of gallstones.