Gallstones - Cholecystitis and Biliary Colic

Overview

The presence of gallstones is a medical condition known as cholelithiasis. Gallstones are solid deposits that form inside the gallbladder, the small pouch-like vessel located posterior to the liver.

Gallbladder with cystic duct and surrounding anatomyThe liver produces a fluid called bile that is stored inside the gallbladder until it is needed to digest food. Bile flows from the gallbladder through a tube called the cystic duct, enters the common bile duct, and then empties into the small intestine to aid in fat digestion.

In some individuals, bile forms crystals that eventually grow larger in size and become gallstones. Most gallstones consist of cholesterol, which is a type of fat, while other gallstones, called pigment stones, are composed of bilirubin, calcium salts, and a variety of other substances.

 

Causes and Risk Factors

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Gallstones inside gallbladder and bile ducts

Cholesterol gallstones are more common in women than in men. Additional risk factors include:

  • Age over 40
  • Rapid weight loss
  • Diabetes
  • Obesity
  • Pregnancy
  • Taking birth control pills
  • Estrogen hormone replacement
  • Family history of gallstones
  • Native American or Mexican American ethnicity

Pigment gallstones are more likely to occur in patients with cirrhosis of the liver or hemolytic states, such as sickle cell disease.

Symptoms

Over 70% of individuals with gallstones have no symptoms at all. In these cases, the gallstones are usually detected as an incidental finding on an unrelated test and typically do not require treatment.

Biliary colic occurs when gallstones intermittently obstruct the cystic duct, causing the following symptoms:

  • A steady, sharp pain in the right upper quadrant of the abdomen
  • Nausea
  • Vomiting
  • Heartburn
  • Gas
  • Fever

Attacks of biliary colic are often precipitated by ingestion of a large or fatty meal.

Acute cholecystitis occurs when a gallstone obstructs the cystic duct with such persistence that the gallbladder becomes distended and inflamed. If a patient has jaundice (a yellowing of the skin), the common bile duct is usually obstructed (choledocholithiasis).

Diagnosis and Treatment

A physical examination typically shows right upper quadrant abdominal tenderness and occasionally an abnormal gallbladder is palpable by the examiner. Laboratory tests may show an elevated white blood cell count. Additionally, a mild elevation of serum bilirubin may occur.

A right upper quadrant ultrasound of the abdomen is a reliable test for detecting the presence of gallstones; however, when the ultrasound does not show gallstones, a hepatic iminodiacetic acid (HIDA) scan may be ordered to confirm a clinical diagnosis of acute cholecystitis. A HIDA scan shows the movement of radioactive dye through the gallbladder and detects an obstructed cystic duct.

Symptomatic patients are treated with intravenous antibiotics and surgery to remove the gallbladder in a procedure known as cholecystectomy. The most common and least invasive approach is a laparoscopic cholecystectomy in which cameras are inserted into the abdomen through small slit-like incisions, and the gallbladder is viewed on a monitor as it is removed. The advantage of this approach is a faster recovery and shorter hospitalization. If laparoscopic surgery is unsuccessful, an alternative approach called open cholecystectomy is used. An open procedure requires a larger incision and a longer hospital stay for recovery.

If gallstones block the common bile duct, the treatment includes an endoscopic retrograde cholangiopancreatography (ERCP), a procedure to remove the blockage and reopen the duct. During an ERCP, an instrument is inserted through the patient’s mouth and passed through the small intestine where stones are visualized and extracted from the bile duct.

Prevention

A healthy body weight and proper nutrition can decrease a person’s risk of gallstones.

Obesity has a negative impact by increasing the body’s level of cholesterol. Additionally, skipped meals, fasting, and rapid weight loss increase the liver’s production of cholesterol in bile. Diets that are high in calories, low in fiber, and high in refined carbohydrates also increase the incidence of gallstones.

Sources

  • Doherty GM. Chapter 25. Biliary Tract. In: Doherty GM. eds. CURRENT Diagnosis & Treatment: Surgery, 13e. New York: McGraw-Hill; 2010. http://accessmedicine.mhmedical.com/content.aspx?bookid=343&Sectionid=39702813. Accessed March 24, 2014.
  • Greenberger NJ, Paumgartner G. Chapter 311. Diseases of the Gallbladder and Bile Ducts. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 18e. New York: McGraw-Hill; 2012. http://accessmedicine.mhmedical.com/content.aspx?bookid=331&Sectionid=40727107. Accessed March 24, 2014.
  • Gallstones. WebMD Web site. http://www.webmd.com/digestive-disorders/gallstones. Accessed March 24, 2014.
  • Duncan CB, Riall TS. Evidence-based current surgical practice: calculous gallbladder disease. J Gastrointest Surg. 2012 Nov;16(11):2011-25. http://www.ncbi.nlm.nih.gov/pubmed/22986769. Accessed March 24, 2014.
  • Gallstones: Prevention. Mayo Clinic Web site. http://www.mayoclinic.org/diseases-conditions/gallstones/basics/prevention/con-20020461. Accessed March 24, 2014.
  • Gallstones. National Digestive Diseases Information Clearinghouse, National Institutes of Health Web site. http://digestive.niddk.nih.gov/ddiseases/pubs/gallstones/index.aspx. Accessed March 24, 2014.