Gallstones

Gallstones are very common, with an incidence of 10–15% of the adult population. The majority of people with gallstones are asymptomatic.

ted Gallbladder and Related Structures

How Gallstones are formed?

There are several factors contribute the formation of stones within the gallbladder. Bile is a complex solution composed of bilirubin, cholesterol , fatty acids and various minerals.

When one or more of the major components is present in excess, the solution becomes supersaturated and cholesterol crystals can form within the bile which eventually coalesce to form cholesterol or ‘mixed’ (cholesterol/bilirubin) gallstones. 

Cholesterol supersaturation can result from either excessive hepatic secretion of cholesterol or decreased hepatic secretion of bile salts. 

Mucin secreted by the gallbladder wall serves as a nidus to form crystals.

Loss of gallbladder motility and excessive sphincteric contraction are also involved in gallstone formation.

Risk Factors

Formation of gallstones is affected by genetic and environmental factors. Strong family history, white European and American ethnicity, female gender (10:1 female: male) and previous pregnancies are highly correlated with cholelithiasis.

Addition to that rapid weight loss in morbidly obese patients, total parenteral nutrition and some drugs( Fibrates) also causes supersaturation of bile result in cholesterol gallstone formation.

Other risk factors include a high dietary intake of fats and carbohydrates, a sedentary lifestyle, type 2 diabetes mellitus and dyslipidemia.

Types of Gallstones

There are three major types of gallstones.

  1. Cholesterol stones which are pale in colour. Those rate the most common type.
  2. Pigmneted tones which has black pigmented and brown stones. Which is more commonly seen in patients with haemolytic disorders like thalassemia, sickle cell anaemia
  3. Mixed stones

Presentation

Most of the patient with gallstones are asymptomatic. But in symptomatic patients about 30% will have recurrent symptom within one area and about 90 will have recurrences within five years. 

Presentation of gallstones would be biliary pain, acute cholecystitis or there complications of gallstones which are described later. 

Biliary pain is a acute onset pain which is located most of the time in the upper abdomen with, a vague , persistent pain which last for hours. This is due to the muscle spasm when   the gallbladder contract s to expels a stone stuck in the gallbladder neck. When the stone fall back in to the gallbladder pain resolves. 

Complication of Gallstones

Persistent pain with tenderness over the right upper abdomen is called acute cholecystitis  due to inflammation of the gallbladder and the surrounding peritoneum due to persistent obstruction. 

Persistent obstruction with inflammation of gallbladder may cause distention of the gallbladder with accumulation of mucus secrete by wall within the gallbladder. This is a called a mucocole of gallbladder. When this is infected it is called empyema of gallbladder.

How To Diagnose Gallstones

As the most of the patients with gallstones are asymptomatic they may found to have gallstones wile investigation for another condition or during postmortems.

The gold standard diagnostic test is the ultrasound scan in symptomatic patients specially with acute cholecystitis. Blood investigation like full blood count, CRP and liver function  test would support the diagnosis of acute cholecystitis. CT scans and MRI are the investigations needed to exclude  other conditions like carcinoma of the gallbladder. Those are not routinely practiced unless indicated. When ultrasound scans not showing stones the functional test called HIDA test is occupied for diagnosis of gallstones and cholecystitis. 

Treatment

For asymptomatic patients no treatment is recommend. Expectant management is the option for them. 

The  treatment of choice for patient with acute cholecystitis is cholecystectomy. Previously it was performed as an open surgery but after the introduction of laparoscopic cholecystectomy 98% percent of cholecystectomies are now done laparoscopically all over the world.

The main benefits of laparoscopic surgeries are better visualisation of structures , less post operative pain, less scaring and less hospital stay. 

This surgery would be performed by one umbilical port inserted just above or below the umbilical the optical port, another three ports at epigastric and right hypochondriac area. It will leave only four small scars which would give cosmetically better results. 

The major complications of this surgery are the bleeding and bile duct injury. Identification and management of those complication are beyond the scope of this article. 

There are some none surgical treatments for gallstones like oral bile salts and shock wave lithotripsy they have no proven benefits at the moment.

For prevention of gallstones and there complications regular exercises, weight reduction, healthy diet and management of comorbidities would be helpful.

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