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Gallstones

Published by Bupa's health information team, December 2006.

This factsheet is for people who want to know more about gallstones.

Gallstones are solid lumps or stones that form in the gallbladder or bile duct. They are formed when some of the chemicals stored in the gallbladder harden into a mass.

About one in three women and one in five men have gallstones by the age of 75. Some people get just one large stone; others may have lots of tiny ones.

The gallbladder

The gallbladder is a small bag-shaped organ on the right-hand side of the body, just below the liver. It stores a green liquid called bile, which is produced by the liver to help the body digest fats and other substances. When we eat, bile is released from the gallbladder into the intestines through a narrow tube called the bile duct.

The position of the gallbladder and surrounding structures

What causes gallstones?

Bile contains cholesterol, bile salts and waste products like the pigment bilirubin. Gallstones form when the usual balance of these substances is upset.

There are two basic types of gallstones:

• cholesterol gallstones are the most common, accounting for more than 80 percent of cases. These are formed when there is too much cholesterol in the bile. Cholesterol gallstones are usually yellowish-green in colour
• pigment gallstones are small and dark, and form when there is excess bilirubin in the bile. They tend to develop in people who have liver disease, infections in the bile tubes or hereditary blood disorders such as sickle-cell anaemia

Who gets gallstones?

The factors that contribute to getting gallstones include:

• age - the risk of gallstones increases with age
• gender - women develop gallstones more commonly than men
• being overweight
• rapid weight loss
• race - in the USA it has been found that native Americans are at the highest risk, while black Americans develop gallstones less frequently
• excess oestrogen - pregnancy and hormone replacement therapy (HRT) can increase the chance of developing gallstones

Gallstones are also associated with certain medical conditions including:

• diabetes
• liver disease
• Crohn's disease
• blood disorders like sickle-cell anaemia
• stomach surgery - gallstones are more common if you have had surgery to remove part of your stomach

Symptoms

Despite being very common, most gallstones cause no symptoms at all, and most people aren't aware that they have them. Gallstones that don't cause any symptoms generally don't need any treatment.

However, gallstones may irritate the lining of the gallbladder (this is known as cholecystitis). Or, most commonly, the stones can get stuck in the tubes leading out of the gallbladder (the bile ducts). This can cause an attack of abdominal pain, called biliary colic, which:

• develops quickly
• is severe
• lasts about one to three hours before fading gradually
• isn't helped by over-the-counter painkillers (the kind of remedies you might normally take for a headache or stomach cramp)
• isn't helped by passing wind

The attacks can be quite frightening, and people sometimes fear that the pain is due to a heart attack because it can travel to the right shoulder or arm. Attacks are not frequent, and if they do re-occur they can be weeks or even years apart.

Other symptoms may include:

• feeling, or being, sick
• sweating
• restlessness
• jaundice (yellowing of the skin or the whites of the eyes)

Diagnosis

If stones are suspected, your doctor may do an ultrasound examination. Ultrasound uses sound waves to create images of the internal organs and pinpoint the location of any stones.

A lubricating gel is applied to the skin. A probe, which may look a bit like a thick, blunt pen or sometimes like a mobile phone, is then held against the skin and moved over its surface. Images of the inside of the body are displayed on a monitor.

Blood and/or urine tests may be done to check for signs of infection, inflammation, jaundice or problems with the pancreas.

Treatment

Watchful waiting

Sometimes gallstones are found by chance during medical tests for other conditions. If they aren't causing any symptoms, they can usually be left alone, as most will not go on to cause problems. This "wait and see" approach is called expectant management or "watchful waiting".

Surgery

People can normally live without a gallbladder, and the most common treatment for gallstones that are causing problems is surgical removal of the gallbladder. This is known as cholecystectomy (pronounced "co-lee-sist-ect-omy"). There are several surgical options.

Laparoscopic cholecystectomy (keyhole gallbladder removal) - This is the most common treatment. Under general anaesthesia a hollow needle is inserted through or near your navel. This is used to inflate the abdomen with carbon dioxide gas. The laparoscope (a long, thin telescope with a light and camera lens at the tip) is then inserted through a small cut at the same spot. This gives the surgeon a view of your internal organs on a video monitor. To remove the gallbladder, specially adapted surgical instruments are then inserted through some more small incisions. Three are usually necessary. Each one of the incisions is only five to 10mm (up to half an inch) long. The operation lasts between 60 and 90 minutes. At the end of the operation, the instruments are removed and the wounds are closed with stitches or clips.

Open surgery - Sometimes, keyhole surgery is not possible and an open cholecystectomy is needed. This involves the removal of the gallbladder under general anaesthesia through a larger cut in the abdomen.

These operations are generally safe, and for most people the benefits (improved symptoms) are greater than any potential problems. However, all surgery does carry some risk. The most common complication in gallbladder surgery is damage to the bile ducts. If this happens you may need more surgery. Your surgeon can discuss the risks and side-effects with you.

Non-surgical treatment options

In special situations (for example, if you can't have general anaesthesia, or don't want to have surgery), you may need to have non-surgical treatment.

Dissolution - This uses medicines to dissolve the gallstones. But this treatment is not suitable for everyone and may take a very long time.

Shock wave lithotripsy - This is a procedure that uses high-energy sound waves to break stones into tiny fragments. This is then followed by medicines to dissolve the small fragments. This treatment is not suitable for everyone because it doesn't work for all types of gallstone.

Endoscopic retrograde cholangio-pancreatography (ERCP) - This type of treatment aims to remove the gallstones without surgically removing the gallbladder. The procedure is usually done under sedation - so you are awake but relaxed and comfortable during the procedure. A thin, flexible telescope called an endoscope is put into the mouth and down through the digestive system to the gallbladder. Special instruments can be passed inside the endoscope to help the doctor see the gallstones, or to remove them. Sometimes, ERCP is done in addition to surgical removal of the gallbladder.

Can gallstones be prevented?

Many of the risk factors for gallstones - your gender, your age and your race for example - can't be altered. Vegetarians develop fewer gallstones, so it might help to increase your fresh fruit and vegetable intake, and reduce the amount of animal products in your diet.

Further information

• Core (Digestive Disorders Foundation)
  020 7486 0341 (please note this is not a helpline)
  www.corecharity.org.uk

Sources

• Martin DJ, Vernon DR, Toouli J. Surgical versus endoscopic treatment of bile duct stones. Cochrane database of systematic reviews.
  www.cochrane.org
  accessed 7 November 2006
• Ranshohoff DF, Gracie WA. Treatment of gallstones. Annals of internal medicine 1993; 119(7):606-619

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