In this article, Mr Satya Bhattacharya, Consultant General and Hepatobiliary Surgeon, explains more about gallstonesLumps of solid matter found in the gallbladder., the symptoms they can cause, how they are managed, and the surgical techniques used to remove the gallbladderSmall pear-shaped organ that sits under the liver and that stores bile..
Gallstones are very common. Around 10% of all adults have gallstones and the condition becomes more likely over the age of 40. But only a small proportion of people whose gallbladder contains gallstones experience problems. The most common sign that gallstones are becoming troublesome is biliary colicSevere pain in the upper right-hand side of the abdomen usually caused by gallstones. – pain in the upper right of the abdomenThe part of the body that contains the stomach, intestines, liver, gallbladder and other organs.. Once any sort of symptoms develop, surgery to remove the gallbladder is the only effective treatment.
In the UK around 4.5 million people have gallstones at any one time and 50,000 of them need to have their gallbladder removed each year.
Gallstones are hard particles that form in the gallbladder. This is a small pouch that sits under the liverA large abdominal organ that has many important roles including the production of bile and clotting factors, detoxification, and the metabolism of proteins, carbohydrates and fats. and that functions as a storage bag for bileA fluid produced by the liver, which helps the fat ingested in food to combine with the digestive juices in the gut.. Bile is made in the liver , stored in the gallbladder and passes into the small intestineThe section of gut, or gastrointestinal tract, from the stomach to the anus. through the bile duct. The fluid, which is green and bitter tasting, contains emulsifiers that helps break down fats so they can be more easily digested.
It is common for some of the compounds in bile to become solid and hard. These particles are tiny at first, but they can then attract other particles and grow. Someone with gallstones may have just one large stone, or many smaller ones. The stones themselves contain cholesterolA substance present in many tissues and an important constituent of cell membranes although high concentrations of a certain type of cholesterol in the blood are unhealthy. or calciumAn element that forms the structure of bones and teeth and is essential to many of the body's functions. or bile pigments, or a mixture of two or three different compounds.
Some factors that increase risk include:
A family history of gallstones
Being over 40
Having multiple pregnancies
Having diabetesA disorder caused by insufficient or absent production of the hormone insulin by the pancreas, or because the tissues are resistant to the effects. (type 1 or type 2)
Losing a lot of weight quickly
Factors that make it less likely that gallstones will develop include:
Drinking alcohol in moderation
Eating a diet high in plant fibre (vegetarians tend to be less proneLying face-downwards. to gallstones)
Many people with gallstones will have mild or infrequent attacks of biliary colic. This is the medical term used to describe the sharp pain in the upper right of the abdomen that occurs when the gall bladder tries to push a gallstone into the bile duct. As the gall bladder squeezes hard, this causes pain. If the gallstone is squeezed out into the bile duct and then into the intestine, or falls backwards into the gallbladder, the pain subsides.
This can happen once in a while, or it can happen every so often causing the same type of niggling pain. Attacks of biliary colic can last minutes or a few hours.
More severe symptoms:
Jaundice: your skin and the whites of your eyes turn yellow. This is because a small stone has become lodged in the bile duct, blocking the flow of bile. The pigments in the bile get into the bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid., causing the colour change in your skin and eyes. An operation may be needed to remove the gallstone if it does not pass out of the bile duct.
Pain in the central upper abdomen: the pancreasA gland behind the stomach that produces digestive enzymes and the hormones insulin and glucagon, which together regulate glucose levels in the blood. and gallbladder both have ducts that empty into the intestine through a common opening. If a gallstone from the gallbladder gets stuck at this point, it can block the exit of digestive enzymes from the pancreasA glandular organ that secretes digestive enzymes and hormones., which can cause the pancreas to become inflamed. Pancreatitis is a medical emergency that often needs hospital treatment and surgery to remove the gallstones.
Intense pain in the upper right of the abdomen, feverThe raising of the body temperature above norma, which may be accompanied by symptoms such as shivering, headache and sweating., nausea, vomitingExpusion of the contents of the stomach through the mouth.. This lasts more than a few hours and indicates that the gallstones have irritated the wall of the gallbladder, causing it to become inflamed. Cholecystitis, or inflammationThe body’s response to injury. of the gallbladder, can lead to infectionInvasion by organisms that may be harmful, for example bacteria or parasites., so this is a medical emergency. The gallbladder then needs to be removed, ideally as soon as possible.
Infection in the bile duct can also occur and can cause a mixture of all of these severe symptoms. A bile duct infection is called cholangitisInflammation of the bile duct. and is relatively rare, but can be a serious life-threatening problem.
Many people have gallstones but do not realise this, as they have no symptoms. The presence of stones can be detected during a diagnostic investigation for another medical problem. They show up very well on ultrasound scans, so if you are having one of these, you may find out that your gallbladder contains stones. There is nothing to worry about as long as you have no symptoms. Even though gallbladder removal is a fairly routine operation that is successful in the vast majority of patients, every operation carries some risks. There is no point in having surgery that you do not need.
If you suffer occasional bouts of biliary colic that do not last long, you may find you can cope with them easily and reduce the frequencyApplied to urination, needing to urinate more often than normal, for whatever reason. of the attacks by adopting a low-fat diet. But at this stage you do need to discuss with your doctor if you need tests to exclude other causes of upper abdominalRelating to the abdomen, which is the region of the body between the chest and the pelvis. pain.
Once gallstones begin to cause pain, the pain often keeps recurring and it gradually gets worse. Unfortunately, there are no effective drug treatments to dissolve gallstones and using ultrasoundA diagnostic method in which very high frequency sound waves are passed into the body and the reflective echoes analysed to build a picture of the internal organs – or of the foetus in the uterus. to break up the stones does not work very well in the gallbladder (lithotripsy is used successfully for kidneyOne of two bean-shaped organs that are located on either side of the body, below the ribcage. The main role of the kidneys is to filter out waste products from the blood. stones).
So, once you experience any symptoms, even mild attacks of biliary colic, surgical removal of the gall bladder is the only effective treatment. The only difference between patients who have mild or severe symptoms is the urgency with which the surgery needs to be arranged. If your symptoms become severe and you develop cholecystitisAcute or chronic inflammation of the gallbladder causing severe abdominal pain.
, pancreatitisInflammation of the pancreas, a gland behind the stomach that produces digestive enzymes and the hormones insulin and glucagon. or an infected bile duct, you may need emergency surgery to remove the gallbladder and any stones blocking the bile duct.
Laparoscopic cholecystectomyThe surgical removal of the gallbladder.: this is a minimally invasive technique in which a specialised surgeon removes the gallbladder and the gallstones it contains by making 3-4 small incisions in the abdomen. The instruments and a laparoscopeAn instrument with attached light source, usually connected to a camera, which allows the examination of the organs during keyhole surgery. are inserted through these ports, allowing the surgeon to see the inside of the body on a large screen in the operating theatre. The surgical instruments are manipulated from outside the body and the gallbladder is removed. Because only small incisions are used, recovery after a laparoscopicA keyhole surgical procedure. cholecystectomy is much faster than after open surgery and you can be out of hospital in a day, and back to work in 1-2 weeks (depending on the nature of your work).
Open cholecystectomy: some patients are unable to have laparoscopic surgery – patients with a gallbladder that is very inflamed or scarred, for example. This decision will be taken by your surgical team after assessing all of your risk factors.
Relieving a bile duct blockage: this is usually done with an endoscopic retrograde cholangiopancreaotography (ERCPAn abbreviation for endoscopic retrograde cholangiopancreaticogram.). An endoscopeA tube-like viewing instrument that is inserted into a body cavity to investigate or treat disorders. is introduced through the mouth, stomachthe organ or the body where food is stored and broken down and into the small intestine and the surgeon works directly within the bile duct. But stones in the gall bladder cannot be removed by this method.