Gallstones

What are Gallstones? 

Gallstones are hard deposits that form inside the gallbladder, a small organ located under the liver. You might not even know you have them until they block a bile duct, causing pain you need to get treated immediately. They vary in size from as small as a grain of sand to as large as a golf ball. Some people develop just one gallstone, while others develop many gallstones at the same time. The condition of having gallstones is called cholelithiasis.

The gallbladder is part of the biliary system, which includes the liver and the pancreas. The gallbladder stores bile, a substance that helps your body process fats. When bile contains too much cholesterol or bilirubin and not enough bile salts, or if the gallbladder doesn't empty completely or often enough, gallstones can form.

Impact of Gallstones on Anatomy and Health

Gallstones can cause several health issues:

• Pain: The most common symptom of gallstones is a "gallbladder attack," in which a person experiences intense abdominal pain lasting from one to several hours. This pain results from the gallstones blocking the bile ducts and causing pressure to build up.
• Inflammation: Gallstones can cause inflammation of the gallbladder (cholecystitis), which can result in fever, nausea, and severe abdominal pain.
• Jaundice and bile duct infections: If a gallstone blocks the common bile duct, bile can back up into the liver, causing jaundice (yellowing of the skin and eyes). This can also cause a life-threatening infection of the bile duct.
• Pancreatitis: Gallstones can cause pancreatitis, which is inflammation of the pancreas. This can cause intense abdominal pain and be a serious, life-threatening condition.

Who is Most at Risk for Gallstones?

Certain people have a higher risk of developing gallstones. These risk factors include:

• Being female: Women are more likely to develop gallstones than men. This is because oestrogen can increase cholesterol levels in bile and decrease gallbladder movement, contributing to gallstone formation.
• Age: The risk of gallstones increases with age.
• Obesity: This is a major risk factor for gallstones. It increases the amount of cholesterol in bile, which can facilitate gallstone formation.
• Diet: A diet high in fat and cholesterol and low in fibre can contribute to developing gallstones.
• Family history: Gallstones can run in families, suggesting a genetic link.
• Diabetes: People with diabetes often have high levels of triglycerides, a type of fat that can increase the risk of gallstones.
• Rapid weight loss: If a person loses weight too quickly, the liver secretes extra cholesterol, which can lead to gallstones.
• Certain ethnic groups: Native Americans are genetically predisposed to secrete high cholesterol levels in bile, a gallstone risk factor.

Causes of Gallstones

Gallstones are caused by imbalances in the substances that make up bile. Bile is produced in your liver and stored in your gallbladder until your body needs it to digest fat. Gallstones can form when there's an imbalance in the components that make up bile. Here are the primary causes:

• Cholesterol stones are the most common type and are thought to result when your bile contains too much cholesterol. Normally, your bile can dissolve the cholesterol excreted by your liver. But if your liver excretes more cholesterol than your bile can dissolve, the excess cholesterol may form into crystals and eventually stones.
• Bilirubin stones: Bilirubin is a chemical produced when your body breaks down red blood cells. Certain conditions cause your liver to make too much bilirubin, including liver cirrhosis, biliary tract infections, and certain blood disorders. The excess bilirubin contributes to gallstone formation.
• Insufficient bile salts: Bile salts are bile chemicals that help break down fats. If bile contains too much cholesterol and not enough bile salts, cholesterol gallstones may form.
• Gallbladder not emptying correctly: If the gallbladder doesn't empty completely or often enough, bile may become very concentrated, contributing to the formation of gallstones.

Symptoms of Gallstones

Many people with gallstones don't have any symptoms and are unaware of their condition. These so-called "silent" gallstones usually don't require treatment. However, if a gallstone blocks one of the bile ducts, it can cause symptoms like

• Sudden and rapidly intensifying pain in the upper right portion of your abdomen or at the centre, just below your breastbone.
• Back pain between your shoulder blades or pain in your right shoulder.
• Nausea or vomiting.
• Fever or chills.
• Jaundice (yellowing of your skin and the whites of your eyes).
• Dark urine and clay-coloured stools.

Types of Gallstones

Gallstones are generally categorised into 

• Cholesterol stones are by far the most common type and may be yellowish in colour. They are made up of more than 50% cholesterol. Cholesterol stones are thought to form when bile fluid contains too much cholesterol or bilirubin and not enough bile salts.
• Pigment stones: These stones are dark and made of bilirubin, a byproduct of red blood cells broken down by the liver. Pigment stones can be further divided into black and brown pigment stones. Black pigment stones form in the gallbladder when there is increased destruction of red blood cells, causing an excess of bilirubin. Brown pigment stones contain more cholesterol and calcium salts, which tend to form when an infection occurs along the biliary tract.

Stages of Gallstone Formation

The formation of gallstones is a process that happens over time and could be understood as having three main stages:

• Supersaturation: The first stage involves a supersaturation of substances (like cholesterol or bilirubin) in the bile. The liver produces bile, which helps in the digestion of fats. If the bile contains too much cholesterol or bilirubin, it can lead to the formation of crystals.
• Nucleation: After supersaturation, small crystals form in the gallbladder from these substances, marking the start of gallstone formation. This process is known as nucleation.
• Growth: Once nucleation begins, gallstones can grow in size and number. Over time, these can lead to symptoms and complications if they become large enough or block any of the bile ducts.

Diagnosis of Gallstones

Gallstones are often found during tests for other conditions. Still, when gallstones are suspected to cause symptoms, the doctor will likely do an ultrasound exam. An ultrasound is the most effective and safe way to detect the presence of gallstones.

Further tests may include

• Computed tomography (CT) scan: The CT scan can show gallstones or complications, such as infection and rupture of the gallbladder or bile ducts.
• Magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP): These tests can show the bile ducts and can detect gallstones, blockages, and signs of infection or inflammation in the bile ducts.
• Hepatobiliary iminodiacetic acid (HIDA) scan or a cholescintigraphy: This test can check whether the gallbladder empties correctly.
• Blood tests: Blood tests can reveal an infection, jaundice, pancreatitis, or other complications caused by gallstones.

Treatment for Gallstones

The treatment for gallstones typically depends on whether they're causing symptoms or not.

• No symptoms: In many cases, gallstones don't cause symptoms and therefore don't need treatment.
• Symptoms present: If you're experiencing symptoms from gallstones, treatment options include:
• Surgery: The most common treatment for symptomatic gallstones is surgical gallbladder removal (cholecystectomy). The gallbladder isn't an essential organ; your body can function normally without it.
• Medication: Certain medications can dissolve gallstones, but this process can take months or years. Medication is generally considered only in cases where the patient isn't a good candidate for surgery.
• Endoscopic retrograde cholangiopancreatography (ERCP): This procedure is often used if a stone needs to be removed from the common bile duct. A flexible tube (endoscope) is passed down the throat, through the stomach, and into the small intestine. A small instrument is then used to remove or break the gallstone.

What if Gallstones are Untreated?

While many gallstones do not cause symptoms and thus don't need treatment, untreated symptomatic gallstones can lead to various complications, including:

• Inflammation of the gallbladder can cause severe pain, fever, and jaundice.
• Common bile duct blockage can cause jaundice, bile duct infection, and, occasionally, severe bloodstream infection (sepsis).
• Blockage of the pancreatic duct can cause pancreatitis, a serious, potentially fatal condition.
• Though rare, gallstones are associated with a higher risk of gallbladder cancer.

So if you have symptoms suggestive of gallstones, it's important to seek medical help. Your doctor can help determine whether your symptoms are due to gallstones or some other condition, and they can guide you in choosing the best treatment approach.