Gallstones

 

Background information

• About 15% of people in New Zealand will develop gallstones over a lifetime.

 

• They are more common in;
  • Women.
  • People who are overweight.
  • Family history of gallstones.

 

• There are several different types of gallstones.
  • Most stones are formed from a supersaturated solution of cholesterol in the gallbladder.
  • Only 10% of gallstones will show on a plain X-ray.
  • Most gallstones are picked up on abdominal ultrasound.

 

• Most stones start as a small cholesterol crystal.
  • The crystal slowly grows depending on the saturation of bile salts and cholesterol in the bile.
  • The function of the gallbladder may be important.  Failure to empty normally could an important factor.
• Pigment stones (10% of all gallstones).
  • These occur because of increased breakdown of blood.

 

 

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Biliary colic – gallstone pain.

• Stones in the gallbladder may cause abdominal pain - this is called biliary colic.
  • This pain is usually an “attack” with sudden onset and lasts for 4-6hours.
  • The pain is mainly in the right upper abdomen but can also be in the lower chest and back (over the right shoulder blade).
  • There is often nausea and/or vomiting.  You may appear to be pale and have excess sweating
  • The severity of the pain is often enough to want to seek out urgent medical attention.
  • Sometimes the pain is confused for a heart attack.
  • There can be repeated episodes of pain but not usually daily episodes.

 

• Biliary colic is caused by a stone lodging in the outlet of the gallbladder.
  • Most of the time the stone falls back into the gallbladder and the “attack” is over.
  • Biliary colic may be brought on by a large fatty meal because this causes strong contractions of gallbladder.

 

• If the pain lasts for more than 6 hours then a complication may have arisen.
  • The main potential complication is inflammation of the gallbladder.  This is called acute cholecystitis.  Hospital admission is essential.
  • Another complication is migration of a stone to the main bile duct. This leads to jaundice;  often infection (cholangitis) or pancreatitis.

 

• Treatment involves
  • Intravenous fluids, pain relief, antibiotics.
  • Then proceeding to cholecystectomy (removal of the gallbladder) – usually during the same hospital admission.
  • Sometimes there is a preference for waiting for the inflammation to settle down before proceeding to surgery.

 

 

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Gallstones on ultrasound but no pain.

 

• This is a common situation. Ultrasound of the abdomen is a common investigation that is done for a wide variety of reasons.
• Many gallstones that are picked up on ultrasound will be causing no symptoms.
  • 60 - 80% of all gallstones cause no problems.
  • About 20% of people with gallstones picked up by chance will develop symptoms due to the gallstones over the next 20 years.
  • Therefore most people would think that watching and waiting is the best response rather than an operation.

 

• Symptoms of indigestion, fullness or bloating after meals, nausea or heartburn are not due to gallstones.

 

 

 

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Gallstone type of pain but no gallstones

• This is also a common situation. Pain in the right upper abdomen may be similar to gallstone pain (biliary colic) but no stones are found when the ultrasound is done.

 

• The most likely explanation is that the pain does not arise from the gallbladder but from the colon or from the stomach.
  • Pain from the colon is due to irritable bowel syndrome.  Pain with IBS can occur anywhere in the abdomen.
  • Sometimes constipation leads to distension of the colon on the right side of the abdomen and right-sided abdominal pain.
  • A gastroscopy should be performed to check for peptic ulcer or acid reflux.
  • A trial of medical therapy and/or dietary manipulation focused on IBS as a possible diagnosis may be considered first.  Patients with IBS are 7 times more likely to have had a cholecystectomy  - this strongly suggests that cholecystectomy has been inappropriate for many of these patients.

• There is a debate as to whether the gallbladder can give rise to pain in the absence of gallstones.
  • There is some suggestion that a “non-functioning gallbladder” is associated with episodes of pain.
  • This means that the gallbladder does not take up the bile coming down from the liver.
  • This “non-functioning” state can be detected by a radionuclear scan called a HIDA scan.
  • A scan showing a “non-functioning” gallbladder predicts a reasonable success rate with cholecystectomy (perhaps 2/3 will have symptom relief).