Gallstones: Causes, Symptoms, Treatment

Gallstones: Causes, Symptoms, Treatment

In this article, we will describe 10 facts about gallstones. It is largely for health professionals.

Key Points

1. Definition: Gallstones are solid deposits that form in the gallbladder and may lead to biliary colic or more serious complications, including cholecystitis and pancreatitis.
2. Content: They are made up of cholesterol, bilirubin, and calcium salts.
3. Symptoms: They are often asymptomatic but can cause upper pain (especially on the right) or obstructive symptoms (jaundice) when they block the bile ducts.
4. Diagnosis: Is typically confirmed via ultrasound, and treatment options range from watchful waiting to surgical removal of the gallbladder.
5. Risk factors: Include age, female gender, obesity, and certain dietary factors.

1. Definition

• Gallstones, or cholelithiasis, are crystalline deposits that form in the gallbladder, usually composed of cholesterol, bilirubin, or a combination of both.
• When gallstones migrate and obstruct the cystic or common bile duct, they can cause pain (biliary colic) and lead to complications like cholecystitis, cholangitis, or pancreatitis.

2. Epidemiology

• Gallstones are common, affecting about 10–15% of adults in the UK.
• They are more prevalent in women, with a female-to-male ratio of approximately 2:1.
• Gallstone incidence increases with age, and although most gallstones remain asymptomatic, about 20% of affected individuals will develop symptoms or complications.

3. Risk Factors

Several factors increase the risk of gallstone formation:

• Gender: Women are at higher risk, especially during reproductive years.
• Age: Gallstone prevalence rises significantly after age 40.
• Obesity: Excess body weight increases cholesterol levels in bile.
• Rapid Weight Loss: Fasting or rapid dieting promotes gallstone formation.
• Pregnancy: Hormonal changes during pregnancy slow bile flow and increase gallstone risk.
• Genetic Factors: A family history of gallstones can increase individual risk.
• Ethnicity: Certain populations, such as Native Americans, have higher prevalence.
• Dietary Factors: High-fat diets or low-fiber intake may increase risk.
• Other Conditions: Diabetes, liver cirrhosis, and hemolytic anemia are linked to a higher incidence of gallstones.

4. Causes

Gallstones form when the balance of substances in bile – cholesterol, bile salts, and bilirubin – becomes disrupted. This can occur due to:

• Cholesterol Supersaturation: When there is too much cholesterol relative to bile salts, cholesterol crystals form, leading to cholesterol gallstones.
• Bilirubin Excess: Certain conditions (e.g., hemolytic anemias, liver cirrhosis) cause high bilirubin levels, forming pigment stones.
• Bile Stasis: Conditions that reduce gallbladder contraction (e.g., prolonged fasting or pregnancy) promote bile stasis and stone formation.

5. Symptoms

Gallstones are frequently asymptomatic. However, when they cause symptoms, presentations include:

• Biliary Colic: A steady, intense pain in the right upper quadrant (RUQ) or epigastrium, often radiating to the right shoulder blade. Pain is typically triggered by fatty meals and lasts from minutes to hours.
• Nausea and Vomiting: Common in cases of biliary colic or cholecystitis.
• Fever and Chills: Seen in acute cholecystitis or cholangitis.
• Jaundice: Indicative of bile duct obstruction or choledocholithiasis (stone in the common bile duct).

6. Diagnosis

Diagnosis is often clinical, supported by imaging:

• History and Physical Examination: RUQ tenderness, Murphy’s sign (pain on palpation of RUQ during inspiration), and fever may suggest cholecystitis.
• Ultrasound: First-line imaging modality, with high sensitivity for detecting gallstones, particularly in the gallbladder.

Investigation

Additional investigations may be required in complicated cases:

• Liver Function Tests (LFTs): Elevated alkaline phosphatase (ALP) and bilirubin may suggest bile duct obstruction.
• Complete Blood Count (CBC): Leukocytosis may indicate infection (cholecystitis or cholangitis).
• Amylase/Lipase: Raised levels can indicate pancreatitis, often due to a gallstone obstructing the pancreatic duct.
• Endoscopic Retrograde Cholangiopancreatography (ERCP): Both diagnostic and therapeutic, ERCP is used to locate and remove common bile duct stones.
• Magnetic Resonance Cholangiopancreatography (MRCP): A non-invasive imaging alternative to ERCP for detecting bile duct stones.

Differential Diagnosis

Other conditions to consider in patients with RUQ or epigastric pain include:

• Peptic Ulcer Disease: Often presents with burning epigastric pain, related to meals.
• Gastroesophageal Reflux Disease (GERD): Causes epigastric discomfort, often associated with acid regurgitation.
• Acute Pancreatitis: Severe epigastric pain radiating to the back, associated with raised amylase/lipase.
• Acute Appendicitis: Pain may initially present as periumbilical but migrates to the right lower quadrant.
• Hepatitis: RUQ discomfort with jaundice, and significantly elevated transaminases.

7. Treatment

The approach to treatment depends on symptom severity and the presence of complications:

• Asymptomatic Gallstones: Usually managed with observation, as the risk of progression to symptomatic disease is low.
• Symptomatic Gallstones (Biliary Colic):
  • Cholecystectomy: Elective laparoscopic cholecystectomy is the definitive treatment for recurrent biliary colic.
  • Pain Management: NSAIDs are often effective; opioids may be necessary for severe pain.
• Complicated Gallstones:
  • Acute Cholecystitis: Intravenous (IV) antibiotics (e.g., ceftriaxone plus metronidazole), fluid resuscitation, and urgent cholecystectomy (ideally within 72 hours).
  • Choledocholithiasis: Managed with ERCP to remove common bile duct stones, followed by cholecystectomy.
  • Cholangitis: An emergency; treatment includes IV antibiotics, biliary decompression via ERCP, and eventual cholecystectomy.
  • Gallstone Pancreatitis: Managed with supportive care (fluids, analgesia), ERCP for ductal obstruction if required, and delayed cholecystectomy to prevent recurrence.

8. Complications

Gallstones can lead to several complications, especially if untreated:

• Acute Cholecystitis: Infection of the gallbladder, often requiring emergency intervention.
• Choledocholithiasis: Stones in the common bile duct, leading to jaundice or cholangitis.
• Cholangitis: Life-threatening infection of the biliary tree, requiring urgent decompression.
• Gallstone Pancreatitis: Caused by obstruction of the pancreatic duct, which can lead to severe inflammation.
• Gallbladder Empyema or Gangrene: Infection can progress to pus formation (empyema) or tissue death (gangrene) in the gallbladder.

9. Prognosis

• The prognosis for uncomplicated, asymptomatic gallstones is generally excellent, as they rarely progress to complications.
• Symptomatic gallstones managed by cholecystectomy have a good prognosis, with most patients experiencing complete symptom resolution.
• However, the prognosis is guarded in cases of severe complications like cholangitis or gallstone pancreatitis, especially if treatment is delayed.

10. Prevention

Preventive strategies focus on modifiable risk factors:

• Healthy Diet: A diet high in fiber and low in saturated fats may reduce gallstone risk.
• Weight Management: Avoid rapid weight loss; gradual weight reduction is preferable.
• Physical Activity: Regular exercise may help prevent obesity and reduce gallstone risk.
• Avoiding Prolonged Fasting: Regular meals help maintain normal bile flow and prevent stasis.

Summary

We have described 10 facts about gallstones. We hope it has been useful.