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What are gallstones?
Gallstones are small, pebble-like substances that develop in the gallbladder. The gallbladder is a small, pear-shaped sac located below your liver in the right upper abdomen. Gallstones form when liquid stored in the gallbladder hardens into pieces of stone-like material. The liquid—called bile—helps the body digest fats. Bile is made in the liver, then stored in the gallbladder until the body needs it. The gallbladder contracts and pushes the bile into a tube—called the common bile duct—that carries it to the small intestine, where it helps with digestion.
Bile contains water, cholesterol, fats, bile salts, proteins, and bilirubin—a waste product. Bile salts break up fat, and bilirubin gives bile and stool a yellowish-brown color. If the liquid bile contains too much cholesterol, bile salts, or bilirubin, it can harden into gallstones.
The two types of gallstones are cholesterol stones and pigment stones. Cholesterol stones are usually yellow-green and are made primarily of hardened cholesterol. They account for about 80 percent of gallstones. Pigment stones are small, dark stones made of bilirubin. Gallstones can be as small as a grain of sand or as large as a golf ball. The gallbladder can develop just one large stone, hundreds of tiny stones, or a combination of the two.
Gallstones can block the normal flow of bile if they move from the gallbladder and lodge in any of the ducts that carry bile from the liver to the small intestine. The ducts include the
Bile trapped in these ducts can cause inflammation in the gallbladder, the ducts, or in rare cases, the liver. Other ducts open into the common bile duct, including the pancreatic duct, which carries digestive enzymes out of the pancreas. Sometimes gallstones passing through the common bile duct provoke inflammation in the pancreas—called gallstone pancreatitis—an extremely painful and potentially dangerous condition.
- Hepatic ducts, which carry bile out of the liver cystic duct
- Which takes bile to and from the gallbladder common bile duct
- Which takes bile from the cystic and hepatic ducts to the small intestine
If any of the bile ducts remain blocked for a significant period of time, severe damage or infection can occur in the gallbladder, liver, or pancreas. Left untreated, the condition can be fatal. Warning signs of a serious problem are fever, jaundice, and persistent pain.
- Severe pain in the upper abdomen that starts suddenly and lasts from 30 minutes to many hours.
- Pain under the right shoulder or in the right shoulder blade.
- Nausea or vomiting.
- Indigestion after eating high-fat foods, such as fried foods or desserts.
Types of gallstones
Cholesterol gallstones are made primarily of cholesterol. They are the most common type of gallstone. Cholesterol is a fat, however, and bile is an aqueous or watery solution; fats do not dissolve in watery solutions. In order to make the cholesterol dissolve in bile, the liver also secretes two detergents-bile acids and lecithin-into the bile. These detergents, just like dish-washing detergents, dissolve the fatty cholesterol so that it can be carried by bile through the ducts.
Pigment gallstones are the second most common type of gallstone. Pigment is a waste product formed from hemoglobin, the oxygen-carrying chemical in red blood cells. The hemoglobin from old red blood cells that are being destroyed is changed into a chemical called bilirubin and released into the blood. Bilirubin is removed from the blood by the liver. The liver modifies the bilirubin and secretes the modified bilirubin or into bile.
Black pigment gallstones
If there is too much bilirubin in bile, the bilirubin combines with other constituents in bile, for example, calcium, to form pigment (so-called because it is dark brown in color).
Brown pigment gallstones
If there is reduced contraction of the gallbladder or obstruction to the flow of bile through the ducts, bacteria may ascend from the duodenum into the bile ducts and gallbladder.
Other types of gallstones
Other types of gallstones are rare. Ceftriaxone is unusual in that it is eliminated from the body in bile in high concentrations. It combines with calcium in bile and becomes insoluble. Like cholesterol and pigment, the insoluble ceftriaxone and calcium form particles that grow into gallstones. Another rare type of gallstone is formed from calcium carbonate.
Cholecystectomy (removal of the gallbladder surgically) is the standard treatment for gallstones in the gallbladder. Surgery may be done through a large abdominal incision or laparoscopically through small punctures of the abdominal wall. Laparoscopic surgery results in less pain and a faster recovery. Cholecystectomy has a low rate of complications, but serious complications such as damage to the bile ducts and leakage of bile occasionally occur. There also is risk associated with the general anesthesia that is necessary for either type of surgery. Problems following removal of the gallbladder are few. Digestion is not affected, and no change in diet is necessary. Chronic diarrhea occurs in approximately 10% of patients.
Sphincterotomy and extraction of gallstones
Sometimes a gallstone may be stuck in the hepatic or common bile ducts. In such situations, there usually are gallstones in the gallbladder as well, and cholecystectomy is necessary. It may be possible to remove the gallstone stuck in the duct at the time of surgery, but this may not always be possible. An alternative means for removing gallstones in the duct before or after cholecystectomy is with sphincterotomy followed by extraction of the gallstone.
Sphincterotomy involves cutting the muscle of the common bile duct (sphincter) at the junction of the common bile duct and the duodenum in order to allow easier access to the common bile duct. The cutting is done with an electrosurgical instrument passed through the same type of endoscope that is used for ERCP. After the sphincter is cut, instruments may be passed through the endoscope and up into the hepatic and common bile ducts to grab and pull out the gallstone or to crush the gallstone. It also is possible to pass a lithotripsy instrument that uses high frequency sound waves to break up the gallstone. Complications of sphincterotomy and extraction of gallstones include the general anesthesia, perforation of the bile ducts or duodenum, bleeding, and pancreatitis.
Oral dissolution therapy
It is possible to dissolve some cholesterol gallstones with medication taken orally. The medication is a naturally-occurring bile acid called ursodeoxycholic acid or ursodiol (Actigall, Urso). Bile acids are one of the detergents that the liver secretes into bile to dissolve cholesterol. Although one might expect therapy with ursodiol to work by increasing the amount of bile acids in bile and thereby cause the cholesterol in gallstones to dissolve, the mechanism of ursodiol's action actually is different. Ursodiol reduces the amount of cholesterol secreted in bile. The bile then has less cholesterol and becomes capable of dissolving the cholesterol in the gallstones.
There are important limitations to the use of ursodiol:
Due to these limitations, ursodiol generally is used only in individuals with smaller gallstones that are likely to have a very high cholesterol content and who are at high risk for surgery because of ill health. It also is reasonable to use ursodiol in individuals whose gallstones were likely to have formed because of a transient event, for example, rapid loss of weight, since the gallstones would not be expected to recur following successful dissolution.
- It is only effective for cholesterol gallstones and not pigment gallstones.
- It works only for small gallstones, less than 1-1.5 cm in diameter.
- It takes one to two years for the gallstones to dissolve, and many of the gallstones reform following cessation of treatment.
Extracorporeal shock-wave lithotripsy
Extracorporeal shock-wave lithotripsy (ESWL) is an infrequently used method for treating gallstones, particularly those lodged in bile ducts. ESWL generators produces shock waves outside of the body that are then focused on the gallstone. The shock waves shatter the gallstone, and the resulting pieces of the gallstone either drain into the intestine on their own or are extracted endoscopically as in sphincterotomy.
Who is at risk for gallstones?
People at risk for gallstones include:
- Women—especially women who are pregnant, use hormone replacement therapy, or take birth control pills
- People over age 60
- American Indians
- Mexican Americans
- Overweight or obese men and women
- People who fast or lose a lot of weight quickly
- People with a family history of gallstones
- People with diabetes
- People who take cholesterol-lowering drugs
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