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Gallstones

 

Gallstones form when elements in bile harden into small, pebble-like pieces in the gallbladder. Most gallstones are made mainly of hardened cholesterol. If liquid bile contains too much cholesterol, or the gallbladder doesn't empty completely or often enough, gallstones can form.

Who is at risk?

Women are twice as likely as men to have gallstones. The female hormone estrogen raises cholesterol levels in the bile and slows gallbladder movement. The effect is even greater in pregnancy as estrogen levels rise. This helps explain why many women develop gallstones when pregnant or after having a baby. Likewise, if you take birth control pills or menopausal hormone therapy, you have a greater chance of developing gallstones.

You are also more likely to have gallstones if you:

  • have a family history of gallstones
  • are overweight
  • eat a high-fat, high-cholesterol diet
  • have lost a lot of weight quickly
  • are older than 60
  • are American Indian or Mexican American
  • take cholesterol-lowering drugs
  • have diabetes

Symptoms

Sometime gallstones have no symptoms and don't need treatment. But if gallstones move into the ducts that carry bile from the gallbladder or liver to the small intestine, they can cause a gallbladder “attack.” An attack brings steady pain in the right upper abdomen, under the right shoulder, or between the shoulder blades. Although attacks often pass as the gallstones move forward, sometimes a stone can become lodged in a bile duct. A blocked duct can cause severe damage or infection.

Warning signs of a blocked bile duct

If you have any of these symptoms of a blocked bile duct, see your doctor right away:

* pain lasting more than 5 hours

* nausea and vomiting

* fever

* yellowish skin or eyes

* clay-colored stool

Treatment

If you have gallstones without symptoms, you do not require treatment. If you are having frequent gallbladder attacks, your doctor will likely recommend you have your gallbladder removed—an operation called a cholecystectomy.

Surgery

Surgery to remove the gallbladder—a nonessential organ—is one of the most common surgeries performed on adults in the United States.

Nearly all cholecystectomies are performed with laparoscopy. After giving you medication to sedate you, the surgeon makes several tiny incisions in the abdomen and inserts a laparoscope and a miniature video camera. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. While watching the monitor, the surgeon uses the instruments to carefully separate the gallbladder from the liver, bile ducts, and other structures. Then the surgeon cuts the cystic duct and removes the gallbladder through one of the small incisions.

Recovery after laparoscopic surgery usually involves only one night in the hospital, and normal activity can be resumed after a few days at home. Because the abdominal muscles are not cut during laparoscopic surgery, patients have less pain and fewer complications than after " open " surgery, which requires a 5- to 8-inch incision across the abdomen.

If tests show the gallbladder has severe inflammation, infection, or scarring from other operations, the surgeon may perform open surgery to remove the gallbladder. In some cases, open surgery is planned; however, sometimes these problems are discovered during the laparoscopy and the surgeon must make a larger incision. Recovery from open surgery usually requires 3 to 5 days in the hospital and several weeks at home. Open surgery is necessary in about 5 percent of gallbladder operations.

The most common complication in gallbladder surgery is injury to the bile ducts. An injured common bile duct can leak bile and cause a painful and potentially dangerous infection. Mild injuries can sometimes be treated nonsurgically. Major injury, however, is more serious and requires additional surgery.

If gallstones are present in the bile ducts, the physician—usually a gastroenterologist—may use ERCP to locate and remove them before or during gallbladder surgery. Occasionally, a person who has had a cholecystectomy is diagnosed with a gallstone in the bile ducts weeks, months, or even years after the surgery. The ERCP procedure is usually successful in removing the stone in these cases.

Nonsurgical treatment

Nonsurgical approaches are used only in special situations—such as when a patient has a serious medical condition preventing surgery—and only for cholesterol stones. Stones commonly recur within 5 years in patients treated nonsurgically.

  • Oral dissolution therapy. Drugs made from bile acid are used to dissolve gallstones. The drugs ursodiol (Actigall) and chenodiol (Chenix) work best for small cholesterol stones. Months or years of treatment may be necessary before all the stones dissolve. Both drugs may cause mild diarrhea, and chenodiol may temporarily raise levels of blood cholesterol and the liver enzyme transaminase.
  • Contact dissolution therapy. This experimental procedure involves injecting a drug directly into the gallbladder to dissolve cholesterol stones. The drug—methyl tert-butyl ether—can dissolve some stones in 1 to 3 days, but it causes irritation and some complications have been reported. The procedure is being tested in symptomatic patients with small stones.

Prevention

Here are some steps you can take to help prevent gallstones:

  • Maintain a healthy weight.
  • If you need to lose weight, do it slowly—no more than ½ to 2 pounds a week.
  • Eat a low-fat, low-cholesterol diet.

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