Abstract

Gallstones are formed in the gallbladder due to an imbalance in the composition of bile or due to stasis. 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 very serious condition), common bile duct obstruction, obstructive jaundice, and cholangitis (can be severe and cause multiple organ failures).

Introduction:

Gallstones are a common condition. Gallstones form in the gallbladder due to an imbalance in the composition of bile. About 1500 ml of bile is secreted by the liver every day.Normally, bile is necessary for digestion of 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. Whenever there is an imbalance of these, the pigments and cholesterol can precipitate and form stones.

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Symptoms:

Asymptomatic: 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, especially, after taking food, in the right upper abdomen. 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 can be 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 calculous can sometimes be complicated and can cause empyema (pus formation in the gallbladder) or perforation (the gallbladder wall can perforate and cause peritonitis, and this 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 its sequelae. Cholecystectomy is recommended in the same admission or once the patient becomes fit, so as to prevent another attack of pancreatitis, 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 blood stream 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 fails, needs decompression of the biliary tract, most commonly by an endoscopic procedure called ERCP (endoscopic retrograde cholangiopancreatography).

Treatment:

Cholecystectomy: Cholecystectomy is the treatment of choice for symptomatic gallstones. A minimally invasive approach can accomplish this, that is, laparoscopic cholecystectomy. Cholecystectomy is now the most common laparoscopic operation performed in the world. It can be performed as a day-case (admission and discharge on the same day) procedure too. The recovery with laparoscopy is fast, and the patient can walk out of the hospital on the same day or the next.

UDCA (Ursodeoxycholic Acid): 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.

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