GALL STONES (Cholelithiasis)

Gallstones occur when bile, which is normally fluid, forms stones.Gallstones commonly contain lumps of fatty (cholesterol-like) material that has solidified and hardened. Sometimes bile pigments or calcium deposits form gallstones. Sometimes just a few small stones are formed; sometimes a great many. Occasionally, just one large stone is formed.
About one in three women, and one in six men, form gallstones at some stage in their life. Gallstones become more common with increasing age. The risk of forming gallstones increases with pregnancy, obesity, rapid weight loss, having a close relative with gallstones, diabetes and if you take certain medicines such as the contraceptive pill.
Understanding the gallbladder and bile
Bile is a fluid made in the liver. Bile contains various substances including bile pigments, bile salts, cholesterol and lecithin. Bile is passed into tiny tubes called bile ducts. The bile ducts join together (like the branches of a tree) to form the main bile duct. Bile constantly drips down the bile ducts, into the main bile duct, and then into the gut.
The gallbladder lies under the liver on the right side of the upperabdomen. It is like a pouch which comes off the main bile duct and fills with bile. It is a ‘reservoir’ which stores bile. The gallbladder squeezes (contracts) when we eat. This empties the stored bile back into the main bile duct. The bile passes along the remainder of the bile duct into the duodenum (the first part of the gut after the stomach).
Bile helps to digest food, particularly fatty foods.
What problems can gallstones cause?
Commonly they cause no problems
Most people with gallstones do not know they have them. It is common to have stones in the gallbladder that cause no symptoms. Gallstones are often found when the abdomen is scanned or X-rayed for other reasons.
Possible problems
About one out of three people with gallstones develop symptoms or problems. Symptoms are more likely to develop in smokers and women who have had a lot of babies. Symptoms include:
Biliary colic. This is a severe pain in the upper abdomen. The pain is usually worst to the right-hand side, just below the ribs. It is caused by a stone that gets stuck in the small tube that takes bile from the gallbladder to the bile duct. The gallbladder then squeezes (contracts) hard to dislodge the stone, and this causes pain. The pain eases and goes if the gallstone is pushed out into the bile duct (and then usually out into the gut), or if it falls back into the gallbladder.

Pain from biliary colic can last just a few minutes but, more commonly, lasts for several hours. A severe pain may only happen once in your lifetime, or it may flare up from time to time. Sometimes less severe but niggly pains occur now and then, particularly after a fatty meal when the gallbladder contracts most.

Inflammation of the gallbladder. This is called cholecystitis. This can lead to infection in the gallbladder. Symptoms usually develop quickly and include abdominal pain, high temperature (fever), and being generally unwell. A patient is normally admitted to hospital to have the gallbladder removed soon if this problem develops.
Jaundice. This is an uncommon complication of gallstones. It occurs if a gallstone comes out of the gallbladder, but gets stuck in the bile duct. Bile then cannot pass into the gut, and so seeps into the bloodstream. This causes you to become yellow (jaundiced). The stone may eventually be passed into the gut. However, it is common to need an operation to remove a gallstone which has become stuck in the bile duct. (Note: there are many other causes of jaundice apart from gallstones.)
Pancreatitis. This is an inflammation of the pancreas. The pancreas makes a fluid rich in enzymes (chemicals which digest food). The pancreatic fluid travels down the pancreatic duct. The pancreatic duct and bile duct join together just before opening into the duodenum. If a gallstone becomes stuck here it can cause pancreatitis which is a painful and serious condition.
How are gallstones diagnosed?
In many cases the symptoms, combined with tenderness in the upper right side of the abdomen, will alert the doctor that this is likely to be gallstones. However, tests are sometimes needed to rule out other conditions such as stomach ulcers, irritable bowel syndrome and tumours. Ultrasound scan and blood tests are the most common investigations done.
What are the treatments for gallstones?
No treatment is needed in most cases. It is often best to leave gallstones alone if they cause few or no symptoms. If symptoms are problematic after fatty food, it makes sense to avoid that type of food.
Medication
Once gallstones start giving symptoms, surgery is the best treatment. However, you may be given painkillers and antibiotic medication if the gallbladder gets infected. Surgery is performed once the infection settles down – usually a week later.
Surgery
An operation to remove the gallbladder is the usual treatment if you have symptoms caused by gallstones.
• Keyhole surgery is now the most common way to remove a gallbladder. The medical term for this operation is laparoscopic cholecystectomy. It is called keyhole surgery, as only small cuts are needed in the tummy (abdomen) with small scars remaining afterwards. The operation is done with the aid of a special telescope that is pushed into the abdomen through one small cut. This allows the surgeon to see the gallbladder. Instruments pushed through another small cut are used to cut out and remove the gallbladder. Keyhole surgery is not suitable for all people.
• Some people with gallstones need a traditional operation to remove the gallbladder. This is called cholecystectomy. In this operation a larger cut is needed to get at the gallbladder.
• Other surgical procedures may be needed if a stone gets stuck in the bile duct.
After a gallbladder is removed
You do not need a gallbladder to digest food. Bile still flows from the liver to the gut once the gallbladder is removed. However, there is no longer any storage area for bile between meals. The flow of bile is therefore constant, without the surges of bile that occur from a gallbladder when you eat a meal.
You can usually eat a normal diet without any problems after your gallbladder is removed. However, up to half of people who have had their gallbladder removed have some mild tummy (abdominal) pain or bloating from time to time. This may be more noticeable after eating a fatty meal. Some people notice an increase in the frequency of passing stools (motions, or faeces) after their gallbladder is removed. This is like mild diarrhoea. It can be treated by antidiarrhoeal medication if it becomes troublesome.

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