Gallstones

Gallstones are the result of an imbalance in bile and an unhealthy gallbladder. When an imbalance occurs, the high cholesterol content in bile crystalises and sticks to the walls of the gallbladder. Over time, they form gallstones which can start from grains of sand and grow to as large as a golf ball. These gallstones irritate the gallbladder and may block the gallbladder, bile ducts/liver or pancreas.

Cholesterol gallstones are caused by increased levels of cholesterol and bilirubin in the bile, as well as reduced levels of bile salts.

Pigment stones tend to occur in people who suffer from liver cirrhosis, infection of the biliary tract, and genetic blood disorders.

Risk factors that may increase the likelihood of gallstones include:

• Cholesterol-reducing drugs which lowers the cholesterol levels in the blood but in the meantime lead to increased secretion of cholesterol in the bile
• Diabetes
• Excess oestrogen levels
• Gender – women aged between 20 and 60 years are more prone to gallstones formation than men
• Increasing age (>60 years)
• Obesity which can lead to high levels of cholesterol in the bile
• Rapid weight loss or prolonged fasting
• Family history

The symptoms of gallstones depend on how, if and where the gallstones block or get lodged in. However, it is important to note, the size or number of gallstones per se is not as important as its presence, as it only takes a single stone to cause symptoms or problems.

Pain is a common symptom, which manifests in different ways. For some, it occurs in the upper right part of the abdomen or in the centre of the abdomen just below the breastbone. Others may experience it in the right shoulder or as back pain between the shoulder blades.

Other symptoms include:

• Abdominal bloating
• Burping
• Fever and chills
• Indigestion
• Jaundice (yellowing of skin and eyes, clay-coloured stools, tea-coloured urine)
• Nausea and vomiting

The symptoms of gallstones usually occur after having a fatty and/or oily meal, and commonly at night. Some people though don’t show any symptoms. They are said to have silent stones, and these stones do not affect the gallbladder, liver or pancreas function.

Occasionally, gallstones may present without significant prior symptoms, with a gallstones-related complications as its first symptoms.

Your doctor will take a comprehensive history and also do a thorough physical evaluation, eg. check your eyes and skin for a yellowish tint that indicates jaundice, which is caused by too much bilirubin in your body. Diagnostic and imaging tests may also be recommended, which include:

• Ultrasound – which allows the doctor to see into your abdomen and confirm the presence of gallstones.
• Abdominal CT scan – to capture images of your liver and abdominal region.
• Blood tests to measure liver function and determine bilirubin levels and any signs of infection or inflammation.
• Magnetic retrograde cholangiopancreatography (MRCP) – a specialised MRI scan of the region to assess the bile ducts to reveal if there are gallstones obstructing the bile ducts.
• Endoscopic retrograde cholangiopancreatography (ERCP) – an endoscopic procedure that employs X-rays to reveal if gallstones may be obstructing your bile duct. This endoscopy can also be potentially therapeutic. For example, it can remove the common bile duct stone, deploy a stent to relieve the jaundice and/or to treat bile duct infections (cholangitis).
• Others methods include a gallbladder radionuclide scan, in which a radioactive dye is injected into your veins and to check the gallbladder’s emptying function. It can also be used to look for bile duct blockage or leakage.

The treatment of gallstones depends on whether they are causing any symptoms, and the likelihood of potential gallstones-related complications. It also depends on your age and your general health. Your doctor will recommend the suitable treatment for your specific condition.

Gallstones can be removed using the following methods:

• Cholecystectomy or gallbladder removal surgery, usually performed as a keyhole surgery known as laparoscopic surgery using several small incisions, or single incision laparoscopic surgery (SILS) which only requires one incision. The surgeon will remove the gallbladder through these incisions and you may be able to return home on the same day. Most people can return to work in a few days.
• Traditional or “open” cholecystectomy may be necessary and more appropriate in some patients and situations (eg. where the infection is severe, anatomy is complicated, or in patients with previous abdominal surgery).
• Medication such as ursodeoxycholic acid, which helps to make the bile less concentrated, may minimise or prevent new stones from forming, and can occasionally dissolve small gallstones. This is often not effective and reserved for patients whose risk for surgery are too high.
• For gallstones dropped in the common bile duct, an ERCP may be used to enter the bile duct via the first portion of the small intestine (duodenum) to retrieve the stones in the common bile duct.
• If necessary, a sphincterotomy may be performed. This involves cutting the sphincter (the muscle between the common bile duct and the duodenum) to widen the exit where remnants or future sludge or smaller stones may pass into the small intestine without causing blockage.

Gallstones can cause complications such as:

• Inflammation and infection of the gallbladder when a gallstone becomes lodged in the neck of the gallbladder. Also known as cholecystitis, it can cause severe pain and fever. If severe, the gallbladder can burst (perforation) and cause widespread infection (peritonitis or sepsis) or it can die (gangrenous).
• Blockage of the common bile duct, obstructing the flow of bile from the liver to the small intestine. It can result in severe pain, jaundice or infection of the bile duct resulting in fever, chills and rigors. If severe, this can lead to potentially serious infections (sepsis).
• Blockage of the pancreatic duct, through which pancreatic juices flow. This can result in inflammation of the pancreas (known as pancreatitis) leading to intense and lasting abdominal pain that may require hospitalisation. If severe, pancreatitis can lead to serious widespread inflammation (Systemic Inflammatory Response Syndrome, SIRS) and potentially life-threatening complications including multi-organ failure, requiring admission into the intensive care unit (ICU) for management.
• Gallbladder cancer, while rare, is associated with a history of gallstone formation and chronic gallbladder inflammation (chronic cholecystitis).