Gallstones (Cholelithiasis)

How do gallstones form?

Gallstones are caused by an imbalance in the bile components.

Cholesterol gallstones are caused by increased levels of cholesterol and bilirubin in the bile, as well as reduced levels of bile salts.

Risk factors for gallstones

Pigment stones tend to occur in people who suffer from liver cirrhosis, infection of the biliary tract, and genetic blood disorders.

There are also other reasons that trigger the formation of gallstones, and these include:

• Cholesterol-reducing drugs which lowers the cholesterol levels in the blood but in the meantime lead to increased secretion of cholesterol in the bile
• Diabetes
• Excess oestrogen levels
• Fasting
• Gender – Women aged between 20 and 60 years are more prone to gallstones formation than men
• Increasing age (>60 years)
• Obesity, which can lead to high levels of cholesterol in the bile
• Rapid weight loss

The mere presence of gallstones is believed to initiate the formation of more gallstones.

The symptoms of gallstones depend on the size, severity and location of your gallstones, and they include:

• Abdominal bloating
• Burping
• Clay-coloured stools
• Fever and chills
• Indigestion
• Jaundice (yellowing of skin and eyes)
• Nausea and vomiting
• Sharp pain in the upper abdomen

The main symptom most people experience is gallstone pain. By themselves, gallstones are not painful. However, if the gallstones block the flow of bile from the gallbladder, you may feel sharp and sudden pain in the upper right portion of your abdomen.

The symptoms of gallstones usually occur after having a fatty meal, and at night. Some people though don’t show any symptoms. They are said to have silent stones, and these stones do not affect the gallbladder, liver or pancreas function.

When to see a doctor

It is best to consult a doctor if you experience any symptoms suggestive of gallstones. You should seek immediate medical attention if you experience any of the following:

• Severe, intense pain
• Pain that persists for more than 5 hours
• Yellowing of skin or eyes
• Fever and chills
• Persistent vomiting
• Persistent lack of appetite
• Clay-coloured stools
• Tea-coloured urine

If your doctor suspects that you have gallstones, they may recommend the following tests to confirm the diagnosis and to evaluate if you have any complications:

• Abdominal ultrasound. This is the most common test to confirm the diagnosis of gallstones. An ultrasound shows images of your gallbladder and bile ducts to detect the presence of gallstones.
• Endoscopic ultrasound. This type of ultrasound allows identification of smaller gallstones that may have been missed in an abdominal ultrasound. The doctor will pass a thin flexible tube called an endoscope through your mouth and into your digestive tract to visualise your gallbladder and bile ducts.
• Cholescintigraphy (HIDA scan). This scan shows how well your gallbladder is working and whether your bile is flowing normally. A harmless radioactive material is injected into your blood, and a special camera is used to visualise the movement of your gallbladder.
• CT scan. A CT scan uses a series of x-rays and computer technology to provide images of the gallbladder, bile ducts and pancreas. It can be used to show gallstones and complications such as infection or inflammation of the pancreas.
• Magnetic resonance cholangiopancreatography (MRCP). This test uses a magnetic field to create pictures of your internal organs, particularly your gallbladder.
• Endoscopic retrograde cholangiopancreatography (ERCP). In an ERCP, the doctor will insert an endoscope and inject a dye so that they can visualise your bile ducts. During the procedure, your doctor can also remove gallstones that are present in the bile ducts.
• Blood tests. Your doctor will order several blood tests to check for complications such as infection, inflammation of the pancreas, and signs of blockage of the bile ducts.

The treatment of gallstones depends on your age and your general health. Your doctor will recommend the most suitable treatment for your specific condition. The gallbladder stones can be left untreated, or they can be removed using the following methods:

• Cholecystectomy – This is a surgical procedure to remove your gallbladder. It can be done through 2 methods – open cholecystectomy or laparoscopic cholecystectomy. The open method involves making a 4 – 6 inch long cut in the upper right side of your abdomen. The laparoscopic method involves 3 – 4 small cuts, through which the surgeon will insert a video camera and the surgical tools. This laparoscopic approach is associated with shorter recovery time and less bleeding compared to the open method.
• Medication to dissolve small gallstones – Treatment of gallstones using medications is less frequently done since it may take months or years before the gallstones become dissolved. Medications are commonly reserved for people who cannot undergo surgery.
• Sphincterotomy – This procedure involves cutting the sphincter (the muscle between the common bile duct and the duodenum) to allow better access to the common bile duct. The surgeon will then extract the gallstones in the common bile duct through the opening.

How to prevent gallstones

A healthy lifestyle can greatly reduce your risk of developing gallstones. Here are some tips to keep your gallbladder healthy:

• Exercise regularly
• Eat a healthy diet that is rich in fibre, fruits and vegetables
• Avoid foods high in saturated fat and cholesterol
• Don’t skip meals
• Avoid extreme dieting that causes you to rapidly lose weight
• Maintain a healthy weight. Being overweight increases your risk of getting gallstones
• For women using hormonal birth control, consult your doctor to determine your risk of developing gallstones

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In some patients, gallstones can cause serious problems if left untreated. The common complications of gallstones include:

• Acute or chronic inflammation of the gall bladder (cholecystitis). If the gallstone blocks the opening of your gallbladder, it can become inflamed and cause fever and pain. If not adequately treated, your gallbladder may even rupture.
• Gangrene of the gall bladder. Untreated cholecystitis can cause the tissue in the gallbladder to die (called gangrene). This can lead to tearing or perforation of the gallbladder.
• Infection of the common bile duct (cholangitis). When the gallstones cause blockage in the bile duct, the bile duct can become infected. The infection can spread to the bloodstream (called sepsis).
• Inflammation of the pancreas (pancreatitis). When gallstones block the opening near the small intestine, it can cause blockage of the pancreatic duct. This leads to pain and inflammation of the pancreas.
• Gallbladder cancer. Although rare, gallstones can increase your risk of getting gallbladder cancer.