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Gall Stones
If the bile contains too much cholesterol or bilirubin, or the gallbladder does not empty properly, then stones can form within the gall bladder. Gallstones can be cholesterol stones, pigment stones or a mixture of the two. Cholesterol stones are largely made of solidified cholesterol. Pigment stones are dark stones made of bilirubin. The majority of stones are mixed stones that contain cholesterol as well as pigment. The gallbladder can develop just one or two large stones (some can be as large as a golf ball), or lots of tiny stones (as small as grains of sand).
Causes of Gallstones
The gallbladder is a small organ in the right upper abdomen under the liver. When healthy, it stores some of the bile that is made by the liver. Bile is necessary to digest and absorb the fats in the foods we eat. When there is an imbalance of the chemicals in the bile, gallstones can form.
A number of causes have been suggested. It is thought that some people secrete more cholesterol than others. As the gallbladder concentrates the bile stored in it, the cholesterol precipitates forming crystals and that these adhere together forming the stones. The stones then tend to enlarge or multiply especially if there is any infection involved. Pregnancy, obesity, weight loss and a family history of gallstones are factors that increase the chances of developing gallstones.
A number of causes have been suggested. It is thought that some people secrete more cholesterol than others. As the gallbladder concentrates the bile stored in it, the cholesterol precipitates forming crystals and that these adhere together forming the stones. The stones then tend to enlarge or multiply especially if there is any infection involved. Pregnancy, obesity, weight loss and a family history of gallstones are factors that increase the chances of developing gallstones.
Risk Factors for Gallstones
Women, particularly between the ages of 20 and 60 years, are more likely to form gallstones than men. In general, those over 60 (men and women) are at a higher risk of developing gallstones. People who are overweight are more likely to form gallstones. Excess estrogen from numerous pregnancies, hormone replacement therapy, or birth control pills may increase cholesterol levels in bile, slow down gallbladder emptying, and lead to gallstones.
People who have biliary infections (for example liver flukes in the tropics) can develop gallstones. Individuals with hereditary blood disorders such as sickle cell anemia (in which too much bilirubin is formed due to the breakdown of blood cells) are more likely to form pigment stones. Going on a diet (with rapid weight loss) and certain cholesterol-reducing drugs can also increase the risk of gallstone formation. A high level of cholesterol in the blood is not necessarily a factor in the development of gallstones. Many people have a “family history” of gallstones but there is no particular gene that has been associated with this.
People who have biliary infections (for example liver flukes in the tropics) can develop gallstones. Individuals with hereditary blood disorders such as sickle cell anemia (in which too much bilirubin is formed due to the breakdown of blood cells) are more likely to form pigment stones. Going on a diet (with rapid weight loss) and certain cholesterol-reducing drugs can also increase the risk of gallstone formation. A high level of cholesterol in the blood is not necessarily a factor in the development of gallstones. Many people have a “family history” of gallstones but there is no particular gene that has been associated with this.
Prevention for Gallstones
There is no special diet you can follow, particular foods you should avoid, or medications you can take to specifically prevent the formation of gallstones. Those who already have pain from gallstones often find that fatty or oily food can trigger the pain. So a low-fat diet can help keep the pain at bay. Gallstones are not related to stones in other parts of the body, particularly stones in the kidneys or in the urinary bladder.
Symptoms of Gallstones
The main symptom is pain, known as gallstone or biliary colic. This commonly occurs in the mid upper abdomen or under the right ribs. It tends to radiate around the rib margin and into the back. It can be precipitated by eating fats. It is severe and can last some hours. The pain usually goes but frequently recurs. In some cases infection sets in, cholecystitis, and the patient develops severe pain under the right ribs with fever. Intravenous antibiotics are necessary to treat the infection and the problem usually takes 3-4 days to settle. If a gallstone passes down the cystic duct into the bile duct it can block the flow of bile leading to jaundice. This is a surgical emergency requiring removal of the obstruction, especially if infection sets in. A stone in the bile duct may also cause inflammation of the pancreas causing a serious condition known as pancreatitis. Rarely, if the stones are left for many years, cancer of the gall bladder may develop.
Often, gallstones remain “silent” and do not cause any symptoms at all. Silent gallstones are usually discovered by accident when tests are done for other problems. The milder symptoms of gallstones include abdominal bloating, belching, indigestion, and nausea, usually after a meal. More severe symptoms include attacks of abdominal pain and vomiting. The pain is usually in the upper abdomen, often more to the right, and can move to the right shoulder blade or shoulder tip. It may come on after meals, especially with fatty foods. This kind of pain is called biliary colic. Most attacks of biliary colic settle after a few hours.
Gallstone can cause symptoms similar to those of a heart attack, appendicitis, bowel obstruction, peptic ulcer, hiatus hernia, pancreatitis, hepatitis and occasionally biliary cancer. It is therefore very important that the correct diagnosis is made.
Often, gallstones remain “silent” and do not cause any symptoms at all. Silent gallstones are usually discovered by accident when tests are done for other problems. The milder symptoms of gallstones include abdominal bloating, belching, indigestion, and nausea, usually after a meal. More severe symptoms include attacks of abdominal pain and vomiting. The pain is usually in the upper abdomen, often more to the right, and can move to the right shoulder blade or shoulder tip. It may come on after meals, especially with fatty foods. This kind of pain is called biliary colic. Most attacks of biliary colic settle after a few hours.
Gallstone can cause symptoms similar to those of a heart attack, appendicitis, bowel obstruction, peptic ulcer, hiatus hernia, pancreatitis, hepatitis and occasionally biliary cancer. It is therefore very important that the correct diagnosis is made.
Diagnosis of Gallstones
To determine if you have gallstones, you will likely undergo an ultrasound, which uses sound waves to detect gallstones and evaluate the bile ducts. If there are abnormalities in the pancreas or bile ducts, additional imaging tests including a CAT scan or magnetic resonance cholangiopancreatography (MRCP), may be necessary. Blood tests can also be helpful if infection or bile duct blockage is suspected.
Complications Caused by Gallstones
Gallstones can lead to acute inflammation of the gallbladder (cholecystitis). Acute cholecystitis is a medical emergency and requires admission to hospital. Treatment has conventionally involved pain killers and antibiotics to settle the acute inflammation, followed six weeks later by an operation to remove the gall bladder. Current best practice involves operating immediately with laparoscopic surgery and this has lead to better outcomes.
Acute cholecystitis caused by aggressive bacteria can cause the gall bladder wall to rot and disintegrate, and the gall bladder may then burst into the abdominal cavity or into an adjacent bit of bowel.
If there have been repeated attacks of inflammation, the gall bladder becomes chronically inflamed, shrunken and scarred. This is called chronic cholecystitis. If the outflow from the gall bladder is totally blocked by a stone it may become a bag full of stagnant bile (a mucocoele) or a bag of pus (empyema).
Gallstones slipping out of the gallbladder into the bile duct can block the flow of bile and cause obstructive jaundice. If you have severe abdominal pain, chills, fever, yellow discoloration of the eyes or skin, or pale stools, you should urgently consult a doctor.
Gallstones passing down the bile duct may also cause inflammation of the pancreas, Acute pancreatitis is a medical emergency, which occasionally escalate into life-threatening complications.
Acute cholecystitis caused by aggressive bacteria can cause the gall bladder wall to rot and disintegrate, and the gall bladder may then burst into the abdominal cavity or into an adjacent bit of bowel.
If there have been repeated attacks of inflammation, the gall bladder becomes chronically inflamed, shrunken and scarred. This is called chronic cholecystitis. If the outflow from the gall bladder is totally blocked by a stone it may become a bag full of stagnant bile (a mucocoele) or a bag of pus (empyema).
Gallstones slipping out of the gallbladder into the bile duct can block the flow of bile and cause obstructive jaundice. If you have severe abdominal pain, chills, fever, yellow discoloration of the eyes or skin, or pale stools, you should urgently consult a doctor.
Gallstones passing down the bile duct may also cause inflammation of the pancreas, Acute pancreatitis is a medical emergency, which occasionally escalate into life-threatening complications.
Silent Gallstones
Silent gallstones that have been detected by chance and have never caused any symptoms do not need treatment. There may be some unusual circumstances where treatment may be recommended for silent gallstones, such as a strong suspicion of cancer, or a patient who will not cope very well with gall bladder inflammation if it develops – Mr Karametos can discuss these with you However, once gallstones have started to cause symptoms it is likely that they will continue to do so.
Treatment for Gallstones
Gallstones are best treated by an operation that removes the gallbladder. This is called a cholecystectomy. The traditional method of cholecystectomy was by open surgery through a long cut under the right edge of the rib cage. Today, most cholecystectomies can be performed by the laparoscopic method (also called ‘key hole’ surgery). If the gallbladder is causing symptoms or if multiple small stones that can escape into the bile duct are present, then removal of the gallbladder is advised. The surgery, when performed, entails removal of the whole gallbladder with the stones inside.
To remove only the stones could result in them reforming after several years and problems returning. The gallbladder is not a vital organ, and absorption and digestion can continue normally after it is taken out. If you have gallstones and don’t remove your gallbladder, you risk infection of the gallbladder (cholecystitis) or bile duct obstruction leading to pancreatitis.
To remove only the stones could result in them reforming after several years and problems returning. The gallbladder is not a vital organ, and absorption and digestion can continue normally after it is taken out. If you have gallstones and don’t remove your gallbladder, you risk infection of the gallbladder (cholecystitis) or bile duct obstruction leading to pancreatitis.
Non- Surgical Treatment for Gallstones
Some medicines do exist that may gradually dissolve gallstones, if taken over a period of time. But they only work for a small number of patients, and once the treatment is stopped the stones generally form again. The drugs (ursodeoxycholic acid and chenodeoxycholic acid) work only for small cholesterol stones, and only if the gallbladder empties properly. Months or even years of treatment may be necessary before all the stones dissolve. The drugs may cause mild diarrhea, and one of them may temporarily raise levels of blood cholesterol and certain liver enzymes. These drugs should be offered only to patients who are unfit to undergo surgery. Stones usually recur after these treatments.
Lithotripsy (using sound waves to break up the stones) can work well for kidney stones, but does not work for gallstones. After they have been broken up, the gallstones may not flush out of the gallbladder. In fact the debris can clog the bile duct and cause additional problems.
Endoscopy (ERCP) can get rid of stones in the bile duct, but stones in the gall bladder cannot be removed this way.
Leaving the gallbladder behind and doing an operation to only remove the stones will mean that the stones can form again. So an operation to surgically remove the gallbladder is the best treatment for gallbladder stones that are causing symptoms.
You may have heard of remedies to “flush out” gallstones. These treatments are unproven, and have no solid scientific evidence to support their use. It is possible that these remedies have benefited some individuals, but to be labelled effective, a treatment has to be shown to work in a majority of patients, when compared against another “standard” treatment or against a placebo.
Lithotripsy (using sound waves to break up the stones) can work well for kidney stones, but does not work for gallstones. After they have been broken up, the gallstones may not flush out of the gallbladder. In fact the debris can clog the bile duct and cause additional problems.
Endoscopy (ERCP) can get rid of stones in the bile duct, but stones in the gall bladder cannot be removed this way.
Leaving the gallbladder behind and doing an operation to only remove the stones will mean that the stones can form again. So an operation to surgically remove the gallbladder is the best treatment for gallbladder stones that are causing symptoms.
You may have heard of remedies to “flush out” gallstones. These treatments are unproven, and have no solid scientific evidence to support their use. It is possible that these remedies have benefited some individuals, but to be labelled effective, a treatment has to be shown to work in a majority of patients, when compared against another “standard” treatment or against a placebo.
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