Patient information: Gallstones

GALLSTONES OVERVIEW

Gallstones are solid, pebble-like collections that form inside the gallbladder. The gallbladder is located in the upper right abdomen, under the liver (figure 1).

More than one million Americans are diagnosed with gallstones (cholelithiasis) every year, joining about 25 million who already have the disorder. Fortunately, most people with gallstones do not have symptoms and do not require treatment. In other cases, gallstones cause pain and must be treated by removing the stone(s) or the entire gallbladder.

More detailed information about gallstones is available by subscription. (See "Nonsurgical treatment of gallstone disease" and "Treatment of acute cholecystitis".)

THE GALLBLADDER

The gallbladder is a pear-shaped muscular organ that is 3 to 6 inches (1.2 to 2.4 cm) long, located in the right upper side of the abdomen, under the liver (figure 2). It is connected to the liver and intestine through small tubes called bile ducts (figure 1).

The primary purpose of the gallbladder is to store and concentrate bile, a greenish-brown fluid that is produced by the liver. Bile is needed for digestion and absorption of fatty foods, as well as for the absorption of important fat soluble vitamins.

Between meals, the gallbladder is relaxed and bile flows into the gallbladder, where it is stored and concentrated (figure 1). With meals, fatty foods in the small intestine triggers the secretion of a hormone (cholecystokinin), which stimulates contraction of the gallbladder. The gallbladder partially empties into the upper region of the small intestine (known as the duodenum). There, the bile aids in the digestion and absorption of fats and fat-soluble vitamins. A few hours later, the gallbladder relaxes and begins to store bile again.

WHAT ARE GALLSTONES?

Gallstones are collections of solid material that form inside the gallbladder. Stones can form in the gallbladder if there is a change or imbalance in the composition of bile or if the gallbladder does not empty completely.

Gallstones may be as small as tiny specks or as large as the gallbladder itself. The vast majority, however, are smaller than 1 inch (2.5 cm) and are one of two major types, cholesterol or pigment. Gallstone type is important since cholesterol stones are more likely to respond to non-surgical treatments than pigment stones.

• Cholesterol gallstones account for approximately 80 percent of gallstones in developed countries, including the United States.
• Pigment stones account for about 20 percent of gallstones.

GALLSTONES RISK FACTORS

The exact reason gallstones develop is not known. However, there are a number of factors that increase the risk of gallstones

• Sex — Gallstones are more common in women.
• Age — The risk of gallstones increases with age. The condition is extremely rare in children and becomes progressively more frequent over time, especially after age 40.
• Family history and genetics — Gallstones are more common in certain families, suggesting that genetics has a role in gallstone development.
• Other factors — Other conditions can increase the risk of developing gallstones, including:

• Pregnancy
• Use of medicines that contain estrogen (such as birth control pills)
• Obesity
• Frequent fasting
• Rapid weight loss (including patients who have surgical weight loss treatments)
• Lack of physical activity
• Diabetes mellitus
• Sickle cell disease (and other conditions associated with rapid destruction of red blood cells, such as in patients with mechanical heart valves)
• Cirrhosis or severe scarring of the liver
• Certain medications

GALLSTONE SYMPTOMS

Silent gallstones — The majority of people who have gallstones do not have symptoms; their stones remain "silent." Silent gallstones are often found on an ultrasound or CT scan done for other reasons. Silent stones do not need to be treated since initial symptoms of gallstones are usually mild and the risk of surgical removal of the gallbladder is greater than the risk of delaying treatment.

If you have silent gallstones, you should be aware of the initial symptoms of gallstone disease because treatment should begin immediately if you develop symptoms (see 'Biliary colic' below; the chance of worsening symptoms increases if treatment is delayed. (See "Approach to the patient with incidental gallstones".)

Biliary colic — Biliary colic, also known as gallstone pain or biliary pain, is the most common symptom of gallstone disease. It is characterized by attacks of abdominal pain, often located in the right upper abdomen just under the lower ribs. You may also feel pain in the back and right shoulder, nausea, and vomiting.

Biliary colic is usually caused by the gallbladder contracting in response to a fatty meal. This compresses the stones, blocking the opening. As the gallbladder relaxes several hours after the meal, the pain subsides.

Once you have a first attack of biliary colic, there is a good chance you will have more severe symptoms in the future.

Acute cholecystitis — Acute cholecystitis refers to inflammation of the gallbladder. It is due to total blockage of the gallbladder caused by repeated episodes of biliary colic. Unlike biliary colic, which resolves within a few hours, pain is constant with acute cholecystitis and fever is common.

Acute cholecystitis is a serious condition that requires immediate medical attention and treatment in the hospital. Treatment includes intravenous fluids, pain medications, and sometimes, antibiotics. Surgical removal of the gallbladder is usually recommended during the hospitalization or shortly thereafter. If not treated, acute cholecystitis can lead to gallbladder rupture, a life-threatening condition. (See "Treatment of acute cholecystitis".)

Complications of gallstones — Complications can develop if gallstones move and block area where bile exits (a condition known as choledocholithiasis).

• Jaundice is a yellow discoloration of the skin and eyes.
• Acute cholangitis is an infection of the bile ducts that causes pain, chills, and fever. This requires prompt treatment, usually involving removal of the gallstone with a non-surgical procedure known as endoscopic retrograde cholangiopancreatography, or ERCP. (See "Patient information: ERCP (endoscopic retrograde cholangiopancreatography)".)

• Acute pancreatitis is sudden inflammation of the pancreas, which is associated with severe abdominal pain. (See "Patient information: Acute pancreatitis".)

GALLSTONE DIAGNOSIS

There are two aspects to the diagnosis of gallstones: determining if gallstones are present, and determining if gallstones are the cause of symptoms.

Gallstones are most commonly detecting using ultrasound, a painless test that uses sound waves to create an image of the gallbladder. Gallstones can also be seen on other imaging tests. These tests may have a role when gallstones are suspected but not seen on ultrasound or if another problem is suspected.

The presence of gallstones does not prove that they are the cause of your symptoms. Thus, other tests may be recommended if there is doubt about the relationship of the gallstones to your symptoms.

GALLSTONE TREATMENT

There are three general options for people with gallstones; the best option depends upon your individual situation.

• Expectant management: Do nothing, wait and watch.
• Surgical therapy: Remove the gallbladder and stones.
• Non-surgical therapy: Eliminate the stones while preserving the gallbladder

Surgical treatment

Cholecystectomy — Cholecystectomy is surgical removal of the gallbladder. It is one of the most commonly performed surgical procedures in the United States. Cholecystectomy requires the use of general anesthesia (to induce sleep and prevent pain) and an operating room.

The gallbladder is an important organ, but is not essential for life. Therefore, the standard treatment for people who suffer from gallstones has been to surgically remove the gallbladder and gallstones. Removing the gallbladder generally has little or no effect on digestion. Loose stools, gas, and bloating develop in about half of patients who undergo surgery; in most patients these symptoms are mild and do not require treatment.

Surgery may be done through an open incision (cut) in the skin. Alternately, the surgery can be done by using small instruments and a video camera, which are inserted into the abdomen through several small incisions. This is called laparoscopic cholecystectomy, and this technique is now the standard way to remove the gallbladder.

Non-surgical treatments — Nonsurgical approaches are available for the treatment of gallstones. These treatments eliminate the stones while preserving the gallbladder. (See "Nonsurgical treatment of gallstone disease".)

Bile acid pill — A bile acid pill (ursodeoxycholic acid or ursodiol) is a medication that can help to break down gallstones. About two-thirds of patients who take it become symptom free within two to three months after starting treatment, and remain symptom free. However, it may take several years for the stones to disappear completely.

Because of its slow action, bile acid treatment is not practical in patients with recurrent or acute (sudden onset) symptoms. It is safe and well tolerated, but mild, temporary diarrhea occurs in some patients. It is only used for people with small cholesterol stones and a functioning gallbladder. It is effective in eliminating stones in about 50 percent of people.

Extracorporeal shock wave lithotripsy — Extracorporeal shock wave lithotripsy (ESWL) uses shock waves to break gallstones into smaller fragments and "sand," which can then be dissolved with an oral bile acid pill.

This treatment is most effective in patients with fewer than 3 stones, patients who are normal weight (not obese), and those with good gallbladder function. The procedure may be uncomfortable, but a sedative or local anesthetic can be given to reduce discomfort. The procedure may cause attacks of biliary pain as fragments pass through the bile duct into the intestine.

Since it relies on bile acid therapy to clear the fractured stones and residue, it can only treat cholesterol stones. The success of ESWL for gallstones varies, with experienced centers successfully treating 90 to 100 percent of patients with one stone and up to 67 percent of patients with two or three stones. (See "Endoscopic management of bile duct stones: Standard techniques and mechanical lithotripsy".)

Gallstone recurrence — The main disadvantage of the non-surgical treatment options is that gallstones can return. With bile acid treatment, stones recur in about 50 percent of people in the first five years. However, symptoms do not always recur and treatment is not always needed if gallstones recur.

Gallstone prevention — The following treatments may be recommended to prevent gallstones from coming back after nonsurgical treatment:

• Eat three well-balanced meals daily, with each meal containing some fat to ensure gallbladder emptying. This prevents collection of bile in the gallbladder.
• Eat a diet that is high in fiber and calcium and low in saturated fats (fat that is solid at room temperature, such as butter, shortening, lard, meat fat).
• Maintain a normal body weight by eating an appropriate number of calories and exercising for at least 30 minutes five days per week. Obese people (with and without known gallstones) who are planning a rapid weight-loss program should be supervised by a healthcare provider and may require treatment with oral bile acids to prevent gallstones from developing during weight loss.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: ERCP (endoscopic retrograde cholangiopancreatography)
Patient information: Acute pancreatitis

Professional Level Information:
Approach to the patient with incidental gallstones
Clinical features and diagnosis of acute cholecystitis
Endoscopic management of bile duct stones: Standard techniques and mechanical lithotripsy
Epidemiology of and risk factors for gallstones
Gallbladder cancer: Epidemiology, risk factors, clinical features, and diagnosis
Nonsurgical treatment of gallstone disease
Patient selection for the nonsurgical treatment of gallstone disease
Treatment of acute cholecystitis
Uncomplicated gallstone disease

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/ency/article/000273.htm, available in Spanish)

• National Institutes Diabetes and Digestive and Kidney Diseases

      (http://digestive.niddk.nih.gov/ddiseases/pubs/gallstones/)

• The American Gastroenterological Association (AGA)

      (www.gastro.org/wmspage.cfm?parm1=688)

• The American College of Gastroenterology (ACG)

      (www.acg.gi.org/patients/cgp/cgpvol2.asp#Gallstones)

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