Gallstones – the biggest stones are often best

Gallstones can cause strong intermittent pain (pain that comes and goes) in the upper right part of the abdomen. The pain can be associated with nausea and retching.

Gallstones form in the gallbladder and consist of deposits of cholesterol and bile salts. The location of gallstones depends on the size of the stone. The biggest stones are often preferable, as they remain in the gallbladder and do not move to the neck of the gallbladder or the bile ducts, where they can cause a blockage resulting in symptoms. The prevalence of gallstones is higher in premenopausal women, but after the menopause, the prevalence is about the same among women and men.

Symptoms

Many people with gallstones experience no symptoms, and the condition is discovered by chance in connection with examination for other stomach complaints. Gallstones that block the gallbladder can cause strong intermittent pain below the lower right rib that can radiate up towards the right shoulder. The pain comes and goes in waves as a result of the resistance causing pain as the gallbladder contracts, and it will be difficult for the patient to lie still. Typically, this pain occurs after eating a fatty meal, or at night. The pain can be associated with nausea and retching. If the pain is accompanied by fever and chills, that is often a sign that the gallbladder is becoming inflamed.

 

Treatment and prevention

The most common treatment for gallstones is primarily painkillers. Surgical removal of the gallbladder is the best treatment for serious cases or repeated attacks.

Asymptomatic gallstones do not require treatment. Painkillers and medication against nausea are administered for gallstone attacks. In many cases, this will be sufficient, but in the long term, the most effective treatment will be to remove the gallbladder to prevent new attacks and future complications. Whether this should be done immediately or some months after the gallstone attack depends on the extent of damage to the gallbladder. The gallbladder can be removed through keyhole surgery or open surgery (opening the abdomen).

If a gallstone is lodged in the bile ducts and not in the gallbladder itself, an ERCP (endoscopic retrograde cholangiopancreatography) examination will be carried out. This is done by passing a tube through the mouth, down into the duodenum and up the bile ducts in order to examine the gall ducts and, if necessary, remove gallstones. If a gallstone is causing inflammation of the gallbladder, antibiotics is administered and surgery will be considered.

It is not recommended for pregnant women to have surgery, since the gallstones will normally disappear after the birth and because surgery during pregnancy carries an increased risk of complications. Gallstones can be prevented by reducing overweight and avoiding very fatty foods and big meals.

Examination and diagnosis

Gallstones are suspected on the basis of classic symptoms and confirmed by ultrasound. A blocked gallbladder will also release substances into the blood that can be identified through a blood test.

 

Causes

There are several factors that make some people more susceptible to gallstones, and fertile women is at higher risk than men and postmenopausal women. Women are especially susceptible to gallstones during pregnancy, since hormones that are active during pregnancy cause the gallbladder to contract less effectively than normal. Overweight, high cholesterol, a history of gallstones in the immediate family, oestrogen therapy in postmenopausal women, rapid weight loss (more than 1.5 kg per week), conditions that impair bile acid absorption or increase the breakdown of red blood cells are all factors that increase the risk of developing gallstones.

Bile is mainly formed in the liver and consists of cholesterol which mixes with yellow and green colour pigments stemming from the breakdown of old blood cells by the liver. Bile aids the digestion of fat and the absorption of fat from the intestine into the blood. The liver produces and releases one litre of bile per day, of which half is temporarily stored in the gallbladder and the rest is released directly from the liver into the duodenum via a network of channels (the bile ducts). The gallbladder contracts to push bile into the duodenum when we eat, and fatty foods in particular stimulates the contraction of the gallbladder. If a gallstone is blocking the gallbladder/bile ducts, the resistance will cause pain as the gallbladder contracts. Since the gallbladder cannot empty itself, the content increases in volume and stretches the gallbladder walls. This can lead to poor blood flow and irritate the gallbladder, which can in turn result in inflammation of the gallbladder.

 

Prognosis

Gallstones that cause classic symptoms and that are not removed leave the patient at increased risk of future attacks and of complications in connection with such attacks. Gallstones that cause symptoms and that are not treated by removing the gallbladder, will increase the risk of future gallstone attacks. Around 25–50 per cent of patients develop complications in connection with future attacks, such as inflammation of the gallbladder, bile ducts or pancreas.