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Gallstones symptoms, causes, treatment – Cholelithiasis

Gallstones are hardened deposits of digestive fluid. Gallstone disease is known as cholelithiasis. Here, we’ll review the essentials of it.

In the United States, around 10-20% of all adults have gallstones. It is a total of approximately 20 million people.

Moreover, every year around 1-3% of patients with gallstones develop symptoms. This equals 500.000 people every year, developing symptoms or complications because of gallstones, needing surgery.

Women are more likely to develop gallstones than men. During their reproductive years, women have 2 or 3 times more chances of having gallstones than men. Also, the risk of developing gallstones increases with age, which results from a higher concentration of cholesterol in bile. 

In the following article, you’ll learn everything you need to know about cholelithiasis. You’ll find the answer to the most frequently asked questions about this condition. From “what is bile and what is it used for?” to the symptoms, diagnosis, and treatment. All of this, explained briefly by a doctor. So, I encourage you to keep reading, and you’ll end up with integral knowledge of this disease.

What are the gallbladder and gallstones? 

The gallbladder is a hollow organ located under your liver, in the abdomen’s upper right quadrant. It has a pear shape and measures 7 to 10cm in length and 4cm in diameter. Its main function is to store a fluid called bile, which is essential in the digestion process. It has a division into three portions: the fundus (rounded base), the body, and the neck. Then, it releases the bile into the cystic duct, which connects to the common bile duct. The gallbladder has a total capacity of 50ml. 

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Gallbladder-Liver-Pancreas Location
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The gallstones are hardened deposits of digestive fluid. They can form anywhere in the biliary tract, but it is more common for them to appear in the gallbladder. Gallstones vary in size; they can be small, like grains of sand, more significant like chickpeas or a golf ball.

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Gallstones
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Furthermore, gallstones can be different colors depending on their composition. They can be of cholesterol or bile pigments (like bilirubin). Patients can have one or multiple gallstones at the same time. They usually develop slowly and can remain without symptoms (asymptomatic) for a while. The medical term for gallstone disease is cholelithiasis. 

What is bile, and what is it used for?

Bile is a dark-green (or brown-yellow) fluid produced by the liver. The liver cells produce it and then stores it in the gallbladder. The composition of the bile is basically water, with a small percentage of bile salts and pigments.

Bilirubin and biliverdin are pigments that result from degrading the hemoglobin of your blood. Both bilirubin and biliverdin are responsible for the brown color of your poop. 

The main function of bile is to digest the fats that we eat. For this, the bile in the gallbladder passes into the duodenum (first portion of the small intestine). When we eat, the gallbladder contracts, sending bile to the cystic duct, then to the common bile duct. Finally, the bile gets to the duodenum through a small opening called the Vater ampulla. Bile helps digest fats by turning them into tiny droplets for later absorption by the intestine. 

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What is the main cause of gallstones?

The main reason for gallstone formation is concentrated bile. When this happens, the substances present in bile can become supersaturated. This results in an excess of these substances that can precipitate and form tiny crystals.

These crystals usually remain in the gallbladder and can grow or get together with other crystals. This way, more giant stones develop and cause gallstone disease or cholelithiasis. 

The production of gallstones can slightly variate depending on the composition of the stones. 

  • Cholesterol gallstones: More than 80% of gallstones have cholesterol as their main component. Liver cells produce cholesterol and then release it to the bile in the form of small bubbles. Once in the bile, bile salts can transform these bubbles into another form with a lower carrying capacity. This means it can carry less cholesterol. It results in excess cholesterol that can precipitate and form crystals and, later, cholesterol stones. These stones are almost exclusively within the gallbladder. 
  • Pigment gallstones: The pigment bilirubin is released into the bile. Bilirubin is the result of the degradation of hemoglobin, which carries oxygen in your red blood cells. Bilirubin can be both conjugated (bonded to proteins) or unconjugated (not bonded to proteins). It’s the unconjugated bilirubin that’s likely to precipitate and form stones. This is why conditions that increase the production of unconjugated bilirubin are risk factors for developing gallstones. In the case of pigment gallstones, they can form in the bile ducts and are more likely to cause obstruction. 

What foods and drinks cause gallstones?

There are no foods or drinks that directly cause gallstones. However, one of the main components of gallstones is cholesterol. Therefore, it is reasonable to avoid food with a high content of cholesterol. Some of these foods include red and fatty meats, sausages, butter, cream, hard cheeses, and fried foods. Importantly, a high alcohol intake can be related to the production of gallstones. On the other side, there are foods with healthy fats (like nuts and fish) that can lower gallstone risk. 

Additionally, since obesity is a risk factor for developing gallstones, you should keep a balanced, healthy diet. This way, you can lower your chances of suffering from this condition. Still, there is little evidence that demonstrates that diet can change the natural history of the disease. 

What are the risk factors for gallstones? 

Like we mentioned before, there are two main types of gallstones based on their composition. Since the way they produce is slightly different, they have different risk factors too. 

Cholesterol gallstones: 

  • Female sex: Since women produce different hormones than men. This makes them keener to produce more cholesterol and, therefore, they have a higher risk of gallstones. 
  • Obesity: The association of it to other conditions like diabetes, insulin resistance, and hypertension are risk factors to increased cholesterol. The higher the cholesterol, the more likely you are to developing gallstones. 
  • Pregnancy: During pregnancy, women produce a hormone called progesterone. This hormone can reduce gallbladder contractility. This can lead to bile retention and greater concentration of bile on the inside.  
  • Certain drugs: Like contraceptive pills, since they contain estrogens that may increase cholesterol production. 
  • Family history of gallstones. 

Pigment gallstones: 

  • Hemolytic disorders: Hemolysis is a process in which there is the destruction of the red blood cells. When this happens, hemoglobin is degraded to bilirubin. Therefore, conditions that cause hemolysis can increase the bilirubin that can form bile duct stones. 
  • Previous biliary surgery: It can cause intraductal stasis (less movement of the bile in the ducts.)
  • Other diseases: Like the ones that affect the small intestine. This can result in lower reabsorption of bile salts, which increases the chance of forming gallstones. 

What symptoms are associated with gallstones?

Most of the time, gallstones can be present in the gallbladder without causing any symptoms. In fact, most patients with asymptomatic gallstones will find out about this condition incidentally. The chance of developing symptoms or any complications is around 1-2% a year. 

In the event of symptomatic gallstones, the most important symptom is the biliary colic. It is an episode of abdominal pain that begins after meals (especially after a fatty meal). It can be intense and dull and usually lasts between 1 to 5 hours. The pain usually appears in the upper right or upper center quadrant of the abdomen. At times, the patient can also feel pain in the right shoulder.

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Abdominal Quadrant Regions
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The severe pain of biliary colic usually increases in intensity in about 10 to 20 minutes. The pain is constant and can’t be relieved with vomits, farts, defecation, or position changes. However, it can resolve spontaneously if the gallbladder stops contracting or the stones fall back into the gallbladder. 

The cause for biliary colic is that gallstones impact the cystic duct when the gallbladder contracts. This increases the gallbladder wall tension, causing pain. Gallbladder pain will get better once the wall relaxes and the obstruction is cleared. Biliary colic can also include nausea, vomiting, and sweating. You must know that episodes of biliary colic are sporadic and unpredictable. 

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Other gallstone symptoms include indigestion, bloating, and fat intolerance. Yet, these symptoms are not specific and can be present in other digestive conditions. 

What are the complications of gallstones?

Even if they stay asymptomatic for a long time, gallstones can still cause some complications. These complications change based on the location of the stones. 

Gallbladder stones inside the gallbladder. These stones usually cause gallbladder diseases like: 

  • Acute cholecystitis: Also known as calculous cholecystitis. It occurs due to the constant impaction of the gallstones in the cystic duct. This results in a distended and inflamed gallbladder. It causes pain similar to the biliary colic, but instead of getting better on its own, it gets worse. It is a surgical emergency that requires medical attention right away. 
  • Gallbladder empyema: This is a collection of discharge (pus) in the gallbladder. It occurs as a result of bacteria overgrowth. This can result in abscesses and perforation of the gallbladder. 
  • Chronic cholecystitis: Repeated episodes of acute cholecystitis can result in fibrosis of the gallbladder wall. This produces a progressive loss of function of the gallbladder. 
  • Gallbladder cancer: Gallstones and chronic cholecystitis can be a risk factor for this type of cancer. 

Stones in the common bile duct. Sometimes, stones can pass by the cystic duct and cause other complications like: 

  • Impaction in the ampulla of Vater: This causes an episode of biliary colic. But, if the obstruction is big, the bile flow from the liver to the intestine gets interrupted. This causes an increase in liver enzymes and jaundice (yellow color of the skin).
  • Ascending cholangitis: An obstructed common duct can get inflamed and infected, affecting the liver and the biliary tree. The obstruction needs to get cleared as soon as possible for the risk of developing sepsis (deadly, generalized infection). 
  • Acute pancreatitis: When a stone impacts the ampulla of Vater, it can obstruct the pancreatic duct too. This triggers an episode of gallstone pancreatitis. Gallbladder pain is different from pancreatitis pain. The latter usually locates in the midabdominal area (often radiates to the back) and is severe, sharp, and continuous. 

What conditions can be mistaken for cholelithiasis?

Many gastrointestinal conditions can coexist with asymptomatic cholelithiasis. Also, many diseases can cause abdominal pain, similar to gallstone pain. Some of the diseases that doctors should think of include

What is the prognosis for gallstones? 

Barely less than half of the patients with gallstones will develop symptoms. The surgical treatment for cholelithiasis is gallbladder removal, and it’s highly effective. After surgery, most patients will have total relief of their symptoms without recurrence.

The gallbladder is not a really necessary organ. Most patients won’t experience any changes after the surgery. However, some patients report changes in their bowel habits and slight abdominal pain after fatty meals. The percentage of patients who die during an elective procedure is around 0.5%. And less than 10% of patients who get complications because of the surgery die. Therefore, this is a disease in which there is a high rate of cure and successful outcomes.

How do you know if you have gallstones?

If you think you may have gallstones, you should go to the doctor. First, they will ask questions about your medical history and the symptoms you’ve been having. Then, they will perform a physical examination.

If you have asymptomatic cholelithiasis, your doctor may not find anything relevant during physical examination. On the other side, if you are experiencing pain at that moment, your doctor will pay more attention to findings. They will palpate your abdomen to locate the pain and differentiate it from other types of abdominal pain. During the physical examination, your doctor can suspect a case of complicated cholelithiasis. At this point, your doctor may indicate some laboratory and imaging studies. 

Alterations in the lab tests include the increase of liver enzymes and rising bilirubin levels. Regarding imaging studies, the abdominal ultrasound is the best method to diagnose gallstones. CT scans can also help visualize other organs. However, it’s more expensive than an ultrasound. There is another procedure called endoscopic retrograde cholangiopancreatography (ERCP). This procedure introduces an endoscope through the duodenum (small intestine) to visualize biliary ducts. Also, the ERCP is great for extracting gallstones impacted in the ampulla of Vater. 

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ERCP
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What is the treatment for gallstones? 

The treatment for gallstones depends on the case of the patient. The most effective way to treat cholelithiasis is gallbladder surgery. However, most patients with gallstones will remain asymptomatic for a long time. If this happens to be the case, surgery is not a recommendation unless the patient experiences symptoms.

Moreover, there are other cases of asymptomatic cholelithiasis in which surgery is recommended. For example, asymptomatic patients with stones of 2cm (or larger) and patients with nonfunctional gallbladder should get surgery. 

The procedure is laparoscopic cholecystectomy. Like in any other laparoscopic surgery, surgeons use a camera and small tools to perform the surgery. This way, doctors can remove your gallbladder, with all its gallstones on the inside. This procedure can also take place as open surgery, called an open cholecystectomy. However, laparoscopic surgery has fewer complications, so it’s the preferred method. 

There is also a medical option for gallstone treatment. This includes the medical dissolution of gallstones using ursodiol (ursodeoxycholic acid). It acts by reducing the saturation of cholesterol in the bile, preventing crystals from forming. Also, it allows a gradual dissolving of the existing stones. The treatment typically requires 6-18 months and is successful only with cholesterol, small stones. Additionally, patients have a 50% chance of recurrence in the following five years. Patients can still develop complications of cholelithiasis until the disappearance is complete.

Do you have symptoms of this disease?

The tool is a Cholelithiasis Symptoms Checker. It gathers the most important signs, symptoms, and risk factors for the disease. Therefore, the tool will tell anybody who uses it the likelihood of their symptoms because of it. Using the tool is free and would take a few minutes.

What do you think?

Written by Dr. Esteban Kosak

Doctor of Medicine - MD Recently Graduated from Medical School and inspired to aid the global population during this situation. I think that we shall no longer be waiting to see a doctor when we feel sick. Several times we feel disease searches in Google drive us to a rabbit hole and come out thinking that we may die of cancer or something very serious, given that symptoms may seem to fit a wide variety of illnesses. Since I recently graduated from medical school. I have all the medical information fresh in my mind. My thorough experience as an expert researcher allows me to very-well known the different diseases and conditions that affect human bodies. Empowered by the United Nations 17 Sustainable Development Goals (SGDs). I think that we all can provide a grain of sand to help humanity. That's why we created Symptoms.Care a place where you can come and screen your symptoms and find what different illnesses can be related to them. Armed with the right information you can instantly, discretely, secure and from the comfort of your home talk with a Doctor that can Evaluate your Symptoms and help you seek the right treatment.

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