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Gallstones are hard, stone-like formations that collect as free, deposited nodules in the gallbladder or bile duct. These stones, varying from the size of a grain of sand to that of a golf ball, form gradually when the materials present in the gallbladder collect and harden.
When gallstones are present in the gallbladder itself, the condition is called cholelithiasis. When gallstones are present in the bile ducts, it is called choledocholithiasis. Gallstones that obstruct bile ducts can lead to severe or life-threatening infection of the bile ducts, pancreas, or liver.
Two types of material form two different types of gallstones: cholesterol stones and pigment stones. Eighty percent of gallstones are cholesterol stones. A person can develop a single stone or several hundred.
Too much or too high a concentration of cholesterol, bile salts, or bilirubin (bile pigment) can cause gallstones. Slow emptying of the gallbladder can also contribute to the formation of gallstones. A microscopic amount of material is thought to harden first and then serve as the nucleus around which other material hardens, until the stones are large enough to begin to cause symptoms.
Cholesterol stones are believed to form when bile contains too much cholesterol, too much bilirubin, not enough bile salts, or when the gallbladder does not empty as it should. Pigment stones tend to develop in people who have cirrhosis, biliary tract infections, and hereditary blood disorders such as sickle cell anemia.
Gallstones are a common condition, and risk factors for them are:
- gender. Women between the ages of 20 and 60 years are twice as likely to develop gallstones than men. Women in their 40s have a high incidence.
- age. The likelihood of gallstones increases with age.
- estrogen. Excess estrogen from pregnancy, hormone replacement therapy, or birth control pills appears to increase cholesterol levels in bile and decrease gallbladder movement, both of which can lead to gallstones.
- ethnicity. Native Americans have the highest rates of gallstones in this country and seem to have a genetic predisposition to secrete high levels of cholesterol in bile.
- cholesterol-lowering drugs. Drugs that lower cholesterol in blood can actually increase the amount of cholesterol secreted in bile, which, in turn, increases the risk of gallstones.
- diabetes. People with diabetes generally have high levels of fatty-acid-based lipids called triglycerides, which increase the risk of gallstones.
- rapid weight loss. As the body metabolizes fat during rapid weight loss, it causes the liver to secrete extra cholesterol into bile, which can cause gallstones.
- fasting. Fasting decreases gallbladder movement, which causes the bile to become over-concentrated with cholesterol.
At first, most gallstones do not cause symptoms. However, when gallstones become larger, or when they begin obstructing bile ducts, symptoms or "attacks" begin to occur. Attacks of gallstones usually occur after a fatty meal and at night.
The most common symptoms of gallstones are:
- recurring pain in the abdomen, referred to as biliary colic;
- jaundice (yellowing of the skin and eyes);
- abdominal bloating;
- intolerance of fatty foods;
- belching or gas;
In some cases, gallstones are discovered by accident during a patient's evaluation for some other purpose. For individuals who have persistent symptoms associated with gallstones, however, the physician will want to take a medical history and perform a physical examination. Diagnostic tests used to identify the presence of gallstones include:
- blood tests (to look for signs of infection, obstruction, jaundice, or pancreatitis);
- CT or MRI;
If gallstones cause no symptoms (are asymptomatic), treatment is usually not necessary. However, if symptoms persist, treatment may include:
- surgery (gallbladder removal, also called cholecystectomy.) In the standard approach, the surgeon removes the gallbladder laparoscopically (using small incisions and endoscopic tools). Alternatively, the surgeon may remove the gallbladder through an open, surgical incision. Bile fluid, no longer stored in the gallbladder, flows directly from the liver to the small intestine. Surgeons in Aria's Division of General Surgery are experts in providing surgery for conditions of the gallbladder.
- oral dissolution therapy. Drugs made from bile acid can sometimes dissolve the stones.
- injected dissolution therapy. A solution or drug, injected into the gallbladder, can dissolve stones.
- extracorporeal shockwave lithotripsy (ESWL). In this procedure, a special machine, called a lithotripter, generates shock waves that can break the gallstones up into tiny pieces that can pass through the bile ducts without causing blockages.
- sphincterotomy. In this procedure, the specialist endoscopically opens the ring of muscle around the end of the bile duct to capture the stones or permit them to pass into the intestine.
If symptoms are mild, the specialist may elect to wait until they resolve somewhat before attempting to remove the stones.