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Gallstones

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Gallstones



Introduction 
 


Gallstones


 

Gallstones are small stones, usually made of cholesterol, that form in the gallbladder. In most cases they do not cause any symptoms and do not need to be treated.

However, if a gallstone becomes trapped in a duct (opening) inside the gallbladder it can trigger a sudden intense abdominal pain that usually lasts between one and five hours. This type of abdominal pain is known as biliary colic.

The medical term for symptoms and complications related to gallstones is gallstone disease or cholelithiasis.

Gallstone disease can also cause inflammation of the gallbladder (cholecystitis). This can cause persistent pain, jaundice and a high temperature (fever) of 38°C (100.4°F) or above.

In some cases a gallstone can move into the pancreas, causing it to become irritated and inflamed. This is known as acute pancreatitis and causes abdominal pain that gets progressively worse.

The gallbladder

The gallbladder is a small, pouch-like organ situated underneath the liver. The main purpose of the gallbladder is to store and concentrate bile.

Bile is a liquid produced by the liver, which helps digest fats. It is passed from the liver through a series of channels, known as bile ducts, into the gallbladder.

The bile is stored in the gallbladder and over time it becomes more concentrated, which makes it better at digesting fats. The gallbladder is able to release bile into the digestive system when it is needed.

What causes gallstones

It is thought that gallstones develop because of an imbalance in the chemical make-up of bile inside the gallbladder. In most cases the levels of cholesterol in bile become too high and the excess cholesterol forms into stones.

Gallstones are very common. It is estimated that more than one in every 10 adults in the UK has gallstones, although only a minority of people will develop symptoms.

You are more at risk of developing gallstones if you are:



overweight or obese



female – women are two to three times more likely to be affected by gallstone disease than men



40 or over – most cases of gallstone disease first develop in people aged 40 or older and the risk increases as you get older



a mother – women who have had children have an increased risk of gallstone disease, which may be because the hormonal changes that occur during pregnancy increase cholesterol levels



Treating gallstones

Treatment is usually only necessary if gallstones are causing symptoms, such as abdominal pain.

In these cases, keyhole surgery to remove the gallbladder may be recommended. This procedure, known as a laparoscopic cholecystectomy, is relatively simple to perform and has a low risk of complications.

You can lead a perfectly normal life without a gallbladder. The organ can be useful but it is not essential. Your liver will still produce bile to digest food, but the bile will just drip continuously into the small intestine, rather than build up in the gallbladder.

Outlook

Most cases of gallstone disease are easily treated with surgery. Very severe cases can be life-threatening, especially in people who are already in poor health, but deaths are rare in the UK.

 

Symptoms of gallstones 

Many people with gallstones do not have any symptoms and are unaware they have them unless they are detected during tests carried out for another reason.

However, symptoms can develop when a gallstone temporarily blocks one of the bile ducts. These are the tube-like structures that carry bile from the liver to the gallbladder and then into the digestive system.

In most cases, this causes abdominal (tummy) pain, although some people also experience other symptoms if the blockage is more severe or a blockage develops in another part of the digestive system.

Abdominal pain

The most common symptom of gallstones is sudden, severe abdominal pain that usually lasts one to five hours (although it can sometimes last just a few minutes). This is known as biliary colic.

The pain can be felt:



in the centre of your abdomen, between your breastbone and belly button



just under the ribs on your right-handside, from where it may spread to your side or shoulder blade



The pain is constant and is not relieved when you go to the toilet, pass wind or are sick. It is sometimes triggered by eating fatty foods, but it can occur at any time of day and it may wake you up during the night.

Biliary colic usually happens infrequently. After an episode of pain, it may be several weeks or months before you experience another episode.

In addition to the pain of biliary colic, some people also have periods where they sweat excessively and feel sick or vomit.

Doctors refer to gallstones that cause episodes of biliary colic as 'uncomplicated gallstone disease'.

Other symptoms

In a small number of people, gallstones can cause more serious problems if they obstruct the flow of bile for longer periods or move into other organs (such as the pancreas or small bowel).

If this happens, you may develop:



a high temperature of 38°C (100.4°F) or above



more persistent pain



a rapid heartbeat



yellowing of the skin and whites of the eyes (jaundice)



itchy skin



diarrhoea



chills or shivering attacks



confusion



a loss of appetite



Doctors refer to this more severe condition as 'complicated gallstone disease'.

When to seek medical advice

If you think you may be experiencing episodes of biliary colic, you should make an appointment with your GP.

Contact your GP immediately for advice if you develop:



jaundice



abdominal pain lasting longer than eight hours



a high temperature and chills



abdominal pain so intense that you cannot find a position to relieve it



If it is not possible to contact your GP immediately, phone your local out-of-hours service or call 111

 

Causes of gallstones 

It is thought that gallstones develop because of an imbalance in the chemical make-up of bile inside the gallbladder. Bile is a liquid produced by the liver to aid digestion.

It is still unclear exactly what leads to this imbalance, but it is known that gallstones can form if:



there are unusually high levels of cholesterol inside the gallbladder – about four in every five gallstones are made up of cholesterol



there are unusually high levels of bilirubin (a waste product produced when red blood cells are broken down) inside the gallbladder – about one in every five gallstones is made up of bilirubin



These chemical imbalances cause tiny crystals to develop in the bile, which gradually grow (often over many years) into solid stones that can be as small as a grain of sand or as large as a pebble.

Sometimes only one stone will form, but there are often several at the same time.

Who’s at risk?

Gallstones are more common in the following groups:



women, particularly those who have had children



overweight or obese people – people who are overweight with abody mass index (BMI) of 25 or above



people aged 40 years or older (the older you are, the more likely you are to develop gallstones)



people with cirrhosis (scarring of the liver)



people with the digestive disorders Crohn’s disease and irritable bowel syndrome (IBS)



people with a family history of gallstones (around a third of people with gallstones have a close family member who has also had gallstones)



people who have recently lost weight, either as a result of dieting orweight-loss surgery such as gastric banding



people who are taking a medication called ceftriaxone, which is an antibiotic used to treat a range of infections, including pneumonia,meningitis and gonorrhoea



Women who are taking the combined oral contraceptive pill or undergoing high-dose oestrogen therapy (which is sometimes used to treat osteoporosis, breast cancer and the menopause) also have an increased risk of developing gallstones.

 

Diagnosing gallstones 

As many people with gallstones do not have any symptoms, theyare often discovered by chance during investigations of unrelated conditions.

If you have symptoms of gallstones, you should make an appointment with your GP so they can try to identify the problem.

Seeing your GP

Your GP will ask about your symptoms in detail and they may carry out a simple test known as the Murphy’s sign test to help determine if your gallbladder is inflamed (which may require urgent treatment).

During this test, your GP will place their hand or fingers on the upper-right area of your tummy and will ask you to breathe in. If you find this painful, it usually indicates that your gallbladder is inflamed.

Your GP may also recommend having blood tests to look for signs of infection, or to check if your liver is working normally. If gallstones have moved into your bile duct, the normal functioning of your liver will be disrupted.

If your symptoms or the results of these tests suggest you may have gallstones, your GP will usually refer you for further tests to confirm the diagnosis. You may be admitted to hospital for tests the same day if your symptoms suggest that you have a more severe form of gallbladder disease.

Further tests

Ultrasound scan

Gallstones can usually be confirmed using an ultrasound scan which uses high frequency sound waves to create an image of the inside of the body.

The type of ultrasound scan used for gallstones is similar to the scan used during pregnancy, where a small handheld device called a transducer is placed onto your skin and moved over your upper abdomen.

Sound waves are sent from the transducer, through your skin and into your body. They then bounce back off the body tissues, forming an image that is displayed on a monitor. This is a painless procedure that usually takes about 10-15 minutes to complete.

When gallstones are diagnosed, there may be some uncertainty about whether any stones have passed into the bile duct.

Bile duct stones are sometimes seen during an ultrasound scan, but if they are not visible and tests you have had suggest the bile duct may be affected (for example, a blood test was abnormal or the bile duct appeared wider than usual during the ultrasound scan), further investigations are needed. In most cases, this will involve an MRI scan or a cholangiogram (see below).

MRI scan

A magnetic resonance imaging (MRI) scan may be carried out to look for gallstones in the bile ducts. This type of scan uses strong magnetic fields and radio waves to produce detailed images of the inside of the body.

Cholangiography

A procedure called a cholangiography can give further information about the condition of your gallbladder.

A cholangiography uses a dye that shows up on X-rays. The dye may be injected into your bloodstream, inserted into your bile ducts during surgery to remove the gallbladder, or inserted into your bile ducts using an endoscope (a long, thin flexible tube with a camera at the end) that is passed through your mouth.

After the dye has been introduced, X-ray images are taken. They will reveal any abnormality in your bile or pancreatic systems. If your gallbladder and bile systems are working normally, the dye will be absorbed in the places it’s meant to go (your liver, bile ducts, intestines and gallbladder).

If a blockage is detected during this test, your doctor may try to remove it at this point using an endoscope. This is known as an endoscopic retrograde cholangio-pancreatography (ERCP). See treating gallstones for more information about ERCP.

CT scan

A computerised tomography (CT) scan may be carried out to look for a complication of gallstones such as acute pancreatitis. This type of scan involves taking a series of X-rays from many different angles.

CT scans are often done in an emergency to diagnose severe abdominal pain.

 

Treating gallstones 

Your treatment plan will depend on how the symptoms are affecting your daily life.

If you don't have any symptoms, a policy of ‘active monitoring’ is often recommended. This means you will receive no immediate treatment, but you should let your GP know if you notice any symptoms.

As a general rule, the longer you go without symptoms, the less likely it is that your condition will get worse.

You may need treatment if you have a condition that increases your risk of developing complications, such as:



scarring of the liver (cirrhosis)



high blood pressure inside the liver – this is known as portal hypertension and can often arise as a complication of alcohol-related liver disease



diabetes



Treatment may also be recommended if a scan shows high levels of calcium inside your gallbladder, as this can lead to gallbladder cancerin later life.

If you have episodes of abdominal pain (biliary colic), treatment will depend on how the pain affects your daily activities. If the episodes are mild and infrequent, you may be prescribed painkillers to control further episodes and given advice about eating a healthy diet to help control the pain.

If your symptoms are more severe and occur frequently, gallbladder removal surgery will usually be recommended. The gallbladder is not an essential organ and most people notice little difference without it.

Keyhole surgery

In most cases, keyhole surgery will be used to remove your gallbladder if surgery is recommended. This is known as a laparoscopic cholecystectomy.

During a laparoscopic cholecystectomy, three or four small cuts (each about 1cm or less) are made in your abdomen. One cut will be by the belly button and the others will be on the right side of your abdomen.

Your abdomen is temporarily inflated using carbon dioxide gas. This is harmless and makes it easier for the surgeon to see your organs.

A laparoscope (a long thin telescope with a tiny light and video camera at the end) is inserted through one of the cuts in your abdomen. This allows your surgeon to view the operation on a video monitor. Your surgeon will then remove your gallbladder using special surgical instruments.

Sometimes, if it's thought there may be gallstones in the bile duct, an X-ray of the bile duct is also taken during the operation. If gallstones are found, they can sometimes be removed during keyhole surgery. If the operation cannot be done this way or an unexpected complication occurs, it may have to be converted to open surgery (see below).

After the gallbladder has been removed, the gas in your abdomen escapes through the laparoscope and the cuts are closed with dissolvable stitches and covered with dressings.

Laparoscopic cholecystectomies are usually performed under ageneral anaesthetic, which means you will asleep during the procedure and won't feel any pain while it's carried out. The operation takes 60-90 minutes and you can usually go home the same day. Full recovery typically takes around 10 days.

Single-incision keyhole surgery

Single-incision laparoscopic cholecystectomy is a newer type of keyhole surgery used to remove the gallbladder. During this type of surgery, only one small cut is made, which means you will only have one barely visible scar.

However, single-incision laparoscopic cholecystectomies haven’t been carried out as often as conventional laparoscopic cholecystectomies, so there are still some uncertainties about it. Access to this type of surgery is also limited because it needs an experienced surgeon with specialist training.

The National Institute for Health and Care Excellence (NICE) has more information on single-incision laparoscopic cholecystectomy.

Open surgery

In some circumstances, a laparoscopic cholecystectomy may not be recommended. This may be due to technical reasons, safety concerns or if there is a stone in the bile duct that cannot be removed another way.

A laparoscopic cholecystectomy may not be recommended if you:



are in the third trimester (the last three months) of pregnancy



are obese – extremely overweight with a body mass index (BMI) of 30 or above



you have an unusual gallbladder or bile duct structure that makes a keyhole procedure difficult and potentially dangerous



In these circumstances, an open cholecystectomy may be recommended. During this procedure, a 10-15cm (4-6in) incision is made in your abdomen underneath the ribs so the gallbladder can be removed. This is done under general anaesthetic, so you will be asleep while it is carried out and won't feel any pain.

Open surgery is just as effective as laparoscopic surgery, but it does have a longer recovery time and causes more visible scarring. Most people have to stay in hospital for up to five days and it typically takes six weeks to fully recover.

Endoscopic retrograde cholangio-pancreatography (ERCP)

An endoscopic retrograde cholangio-pancreatography (ERCP) is a procedure that can be used to remove gallstones from the bile duct. However, the gallbladder is not removed during this procedure so any stones in the gallbladder will remain unless removed using the surgical techniques mentioned above.

ERCP is similar to a diagnostic cholangiography (see diagnosing gallstones for more information), where an endoscope (a long, thin flexible tube with a camera at the end) is passed through your mouth down to where the bile duct opens into the small intestine.

However, during ERCP the opening of the bile duct is widened with a small incision or an electrically heated wire. The bile duct stones are then removed or left to pass into your intestine and out of your body.

Sometimes a small tube called a stent is permanently placed in the bile duct to help the bile and stones pass.

An ERCP is usually carried out under sedation, which means you will be awake throughout the procedure but will not experience any pain.

The ERCP procedure lasts about 30 minutes on average, but it can take anywhere from 15 minutes to over an hour. You may need to stay overnight in hospital after the procedure so you can be monitored.

Medication to dissolve gallstones

If your gallstones are small and don't contain calcium, it may be possible to take ursodeoxycholic acid tablets to dissolve them.

However, these are not prescribed very often because they are rarely very effective, they need to be taken for a long time (up to two years) and gallstones can recur once treatment is stopped.

Side effects of ursodeoxycholic acid are uncommon and are usually mild. The most commonly reported side effects are feeling sick, being sick and itchy skin.

The use of ursodeoxycholic acid is not usually recommended for pregnant or breastfeeding women. Sexually active women should use either a barrier method of contraception, such as a condom, or a low-dose oestrogen contraceptive pill while taking ursodeoxycholic acid, as it may affect other types of oral contraceptive pills.

Ursodeoxycholic acid tablets are occasionally also prescribed as a precaution against gallstones if it is thought that you are at risk of developing them. For example, you may be prescribed ursodeoxycholic acid if you have recently had weight loss surgery, as rapid weight loss can cause gallstones to grow.

 

Complications of gallstones 

In a small number of people with gallstones, serious problems can develop if the gallstones cause a severe blockage or move into another part of the digestive system.

Inflammation of the gallbladder (acute cholecystitis)

In some cases of gallstone disease a bile duct can become permanently blocked, which can lead to a build-up of bile inside the gallbladder. This can cause the gallbladder to become infected and inflamed.

The medical term for inflammation of the gallbladder is acute cholecystitis. Symptoms include:



pain in your upper abdomen that travels towards your shoulder blade (unlike biliary colic, the pain usually lasts longer than five hours)



a high temperature (fever) of 38°C (100.4°F) or above



a rapid heartbeat



An estimated one in seven people with acute cholecystitis will also experience jaundice (see below).

Acute cholecystitis is usually treated first with antibiotics to settle the infection and then keyhole surgery to remove the gallbladder. This operation can be more difficult when performed as an emergency and there is a higher risk of it being converted to an open procedure.

Sometimes a severe infection can lead to a gallbladder abscess (empyema of the gallbladder). Antibiotics alone do not always treat these and they may need to be drained.

Occasionally a severely inflamed gallbladder can tear, leading to peritonitis (inflammation of the thin layer of tissue that lines the inside of the abdomen, called the peritoneum). If this happens, you may need to have antibiotics given directly into a vein (intravenous antibiotics) and surgery may be required to remove a section of the peritoneum if part of it becomes severely damaged.

Jaundice

If a gallstone passes out of the gallbladder into the bile duct and blocks the flow of bile, jaundice occurs.

Symptoms of jaundice include:



yellowing of the skin and eyes



dark brown urine



pale stools (faeces)



itching



Sometimes the stone passes from the bile duct on its own. If it doesn’t, the stone needs to be removed. See treating gallstones.

Infection of the bile ducts (acute cholangitis)

If the bile ducts become blocked, they are vulnerable to infection by bacteria. The medical term for a bile duct infection is acute cholangitis.

Symptoms of acute cholangitis include:



pain in your upper abdomen that travels towards your shoulder blade



a high temperature



jaundice



chills



confusion



itchy skin



generally feeling unwell



Antibiotics will help treat the infection, but it is also important to help the bile from the liver to drain with an endoscopic retrograde cholangio-pancreatography (ERCP). See treating gallstones for more information.

Acute pancreatitis

Acute pancreatitis may develop when a gallstone moves out of the gallbladder and blocks the opening (duct) of the pancreas, causing it to become inflamed.

The most common symptom of acute pancreatitis is a sudden severe dull pain in the centre of your upper abdomen, around the top of your stomach.

The pain of acute pancreatitis often gets steadily worse until it reaches a constant ache. The ache may travel from your abdomen and along your back and may feel worse after you have eaten. Leaning forward or curling into a ball may help to relieve the pain.

Other symptoms of acute pancreatitis can include:



feeling sick



being sick



diarrhoea



loss of appetite



a high temperature (fever) of 38°C (100.4°F) or above



tenderness of the abdomen



less commonly, jaundice



There is currently no cure for acute pancreatitis, so treatment focuses on supporting the functions of the body until the inflammation has passed.

This usually involves admission to hospital so you can be given fluids into a vein (intravenous fluids), pain relief, nutritional support and oxygen through tubes into your nose.

With treatment, most people with acute pancreatitis improve within a week and are well enough to leave hospital after 5-10 days.

Cancer of the gallbladder

Gallbladder cancer is a rare but serious complication of gallstones. An estimated 660 cases of gallbladder cancer are diagnosed in the UK each year.

Having a history of gallstones increases your risk of developing gallbladder cancer. Approximately four out of every five people who have cancer of the gallbladder also have a history of gallstones.

However, people with a history of gallstones have a less than one in 10,000 chance of developing gallbladder cancer.

If you have additional risk factors, such as a family history of gallbladder cancer or high levels of calcium inside your gallbladder, it may be recommended that your gallbladder be removed as a precaution, even if your gallstones aren’t causing any symptoms.

The symptoms of gallbladder cancer are similar to those of complicated gallstone disease, including:



abdominal pain



high temperature (fever) of 38°C (100.4°F) or above



jaundice



Gallbladder cancer can be treated with a combination of surgery, chemotherapy and radiotherapy.

Gallstone ileus

Another rare but serious complication of gallstones is known as gallstone ileus. This is where the bowel becomes obstructed by a gallstone.

There were around 300 hospital admissions for gallstone ileus in England during 2012-13.

Gallstone ileus can occur when an abnormal channel, known as a fistula, opens up near the gallbladder. Gallstones are then able to travel through the fistula and can block the bowel.

Symptoms of gallstone ileus include:



abdominal pain



being sick



swelling of the abdomen 



constipation



A bowel obstruction requires immediate medical treatment. If it is not treated, there is a risk that the bowel could split open (rupture). This could cause internal bleeding and widespread infection.

If you suspect that you have an obstructed bowel, contact your GP as soon as possible. If this is not possible, phone 111.

Surgery is usually required to remove the gallstone and unblock the bowel. The type of surgery you receive will depend on where in the bowel the obstruction has occurred. 

 

Preventing gallstones 

From the limited evidence available, changes to your diet and losing weight (if you are overweight) may help prevent gallstones.

Diet

Because of the role cholesterol appears to play in the formation of gallstones, it is advisable to avoid eating too many fatty foods with a high cholesterol content.

Foods high in cholesterol include:



meat pies



sausages and fatty cuts of meat



butter and lard



cakes and biscuits



A healthy, balanced diet is recommended. This includes plenty of fresh fruit and vegetables (at least five portions a day) and wholegrains.

There is also evidence that regularly eating nuts, such as peanuts or cashews, can help reduce your risk of developing gallstones. 

Drinking small amounts of alcohol may also help reduce your risk of gallstones, but you should not exceed the NHS guidelines of three to four units a day for men and two to three units a day for women as this can lead to liver problems and other health conditions.

Losing weight

Being overweight, particularly being obese, increases the amount of cholesterol in your bile, which in turn increases your risk of developing gallstones. You should therefore control your weight by eating a healthy diet and taking plenty of regular exercise.

However, avoid low-calorie, rapid-weight-loss diets. There is evidence they can disrupt your bile chemistry and increase your risk of developing gallstones. A more gradual weight loss plan is recommended.