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AND GALLBLADDER DISEASE
ARE GALLSTONES AND GALLBLADDER DISEASE?
and the Gallbladder
of gallstones is a complex procedure that starts with bile,
a fluid composed mostly of water, bile salts, lecithin (a fat known
as a phopholipid), and cholesterol. (Most gallstones are formed
- Bile is
first produced by the liver and then secreted through tiny channels
that eventually lead into a larger tube called the common
bile duct , which leads to the small intestine.
- Only a
small amount of bile drains directly into the small intestine,
however. Most flows into the gallbladder through
the cystic duct , which is a side extension off
the common duct. (The system of ducts through which bile flows,
including the common bile duct is called the biliary tree).
- The gallbladder
is a four-inch sac with a muscular wall that is located under
the liver. Here, most of the fluid (about two to five cups a
day) is removed, leaving a few tablespoons of concentrated bile.
- Bile is
important for the digestion of fat. The gallbladder serves as
a reservoir until bile is needed in the small intestine for
- A hormone
called cholecystokinin is released when food enters
the small intestine. Cholecystokinin signals the gallbladder
to contract and deliver bile into the intestine.
- The force
of the contraction propels the bile back down the common bile
duct and then into the small intestine, where it emulsifies
(breaks down) fatty molecules.
- This process
allows the emulsified fat as well as fat-absorbable nutrients,
including vitamins A, D, E, and K, to enter the blood stream
through the intestinal lining.
of Gallstones (Cholelithiasis)
of the gallstones found in the US population are formed from cholesterol.
About 15% of gallstones are known as pigment stones. Patients may
also have a mixture of pigment and cholesterol gallstones. Gallstones
can range from a few millimeters to several centimeters in diameter.
Cholesterol Stones. Cholesterol makes up only five percent
of bile. It is not very soluble, however, so in order to remain
suspended in fluid, it must be properly balanced with bile salts.
If there is an imbalance in bile salts and cholesterol, the following
and cholelithiasis can occur as a result of various abnormalities,
although the cause is not entirely clear. Events that may promote
cholelithiasis include the following:
- The fluid
turns to sludge, which consists of a mucus gel containing cholesterol
and calcium bilirubinate.
- If the
process continues, cholesterol crystals form out of the bile
solution ( supersaturation) and can eventually
- This process
is referred to as cholelithiasis. It is very slow
and most often painless.
Pigment stones are composed of calcium bilirubinate, or calcified
bilirubin. Bilirubin is a substance normally formed by the breakdown
of hemoglobin in the blood and it is excreted in bile. Pigment stones
can be black or brown and often form in the gallbladders of people
with hemolytic anemia (a relatively rare anemia where red blood
cells are destroyed) or cirrhosis.
- The liver
secretes too much cholesterol into the bile.
- The gallbladder
has defective emptying mechanisms so that the bile becomes stagnant
and sludge forms, eventually forming stones.
- The cells
lining the gallbladder may lose their capacity to efficiently
absorb cholesterol and fat from bile.
Effects of Gallstones. Gallstones can cause obstruction at
any point along the ducts that carry bile:
- In most
cases of obstruction, the stones block the cystic duct, which
leads from the gallbladder to the common bile duct. This can
cause pain ( biliary colic ), infection and inflammation
(called cholecystitis), or both.
10% of patients with symptomatic gallstones also have stones
that pass into and obstruct the common bile duct (called choledocholithiasis).
Diseases without Stones
can occur without stones (called acalculous gallbladder disease).
[ See Box Gallbladder Disease without
GALLBLADDER DISEASE WITHOUT STONES
(A CALCULOUS GALLBLADDER DISEASE)
disease can occur without stones (called acalculous gallbladder
disease). It can be acute or chronic.
Acute acalculous gallbladder disease usually occurs in
patients who are very ill from other disorders. In such
cases, inflammation occurs in the gallbladder, usually
from a diminished blood supply or an impairment in the
ability of the gallbladder to contract.
Chronic acalculous gallbladder disease (also called biliary
dyskinesia) appears to be caused by defects in the gallbladder
that impair its ability to contract and release bile.
Diagnosing Chronic Acalculous Gallbladder Disease
acalculous gallbladder disease is usually diagnosed when a
patient complains of gallbladder symptoms but there is no
radiologic evidence of stones. (More than half of patients
initially diagnosed with this disease however, are eventually
shown to have small stones or gallbladder sludge.) The patient
is given the hormone cholecystokinin octapeptide (CCK), which
induces gallbladder contraction, followed by a radioisotope
scan that determines if the gallbladder is emptying correctly.
If the gallbladder demonstrates difficulty releasing bile,
doctors usually consider the diagnosis confirmed.
Treatment for Chronic Acalculous Gallbladder Disease
(75% to 90%) diagnosed with chronic acalculous gallbladder
disease [ see above ] are relieved of their symptoms
by cholecystectomy (removal of the gallbladder). [ See
What Are the Surgical Procedures for Gallstones and Gallbladder
Disease?, below.] More than half of patients are subsequently
shown to have small stones or gallbladder sludge that was
not visible on their ultrasounds. A 2001 study indicates that
a muscle defect might be the cause of the disease in patients
who do not have stones or sludge.
ARE THE SYMPTOMS OF GALLSTONES AND GALLBLADDER DISEASE?
provoke no symptoms at all. If symptoms do occur, the chance of
developing pain is about 2% per year for the first ten years after
stone formation, after which the chance for developing symptoms
declines. On average, symptoms take about eight years to
develop. The reason for the decline in incidence after ten years
is not known, although some physicians suggest that "younger," smaller
stones may be more likely to cause symptoms than larger ones.
The mildest and
most common symptom of gallbladder disease is intermittent pain
called biliary colic , which occurs either in the
mid- or the right portion of the upper abdomen. A typical attack
has several features:
common but attacks can be years apart. In one study, for example,
30% of people who had had one or two attacks, experienced no further
biliary pain over the next ten years.
or fatty meals can precipitate the pain, but it usually occurs
several hours after eating and often wakes the patient during
- The primary
symptom is steady pain on the right side (under the rib cage),
which can be quite severe. Changes in position, over-the-counter
pain relievers, and passage of gas do not relieve the symptoms.
- The patient
may experience nausea or vomiting.
colic typically disappears after one to five hours.
of Acute Cholecystitis (Gallbladder Inflammation)
and infection in the gallbladder ( acute cholecystitis )
are usually caused by gallstones. (In some cases, it can occur without
stones.) The symptoms in either case are similar to those of biliary
colic but are more severe and serious. They include the following:
Anyone who experiences
such symptoms should seek medical attention. Acute cholecystitis
can progress to gangrene or perforation of the gallbladder if left
untreated. (People with diabetes are at particular risk for this
pain and tenderness in the upper right abdomen are the most
common. It also may radiate to the back or occur under the shoulder
blades. Pain frequently occurs when drawing a breath.
- The discomfort
is intense and steady and can last for days.
a third of patients have fever and chills.
and vomiting may occur.
of Chronic Cholecystitis or Dysfunctional Gallbladders
disease ( chronic cholecystitis ) occurs with gallstones
and low-grade inflammation. In such cases the gallbladder may become
scarred and stiff. Symptoms of chronic gallbladder disease include
of gas, nausea, and abdominal discomfort after meals are the
most common, but they may be vague and indistinguishable from
similar complaints in people without gallbladder disease.
- A 2000
study reported that chronic diarrhea (four to 10 bowel movements
every day for at least three months) may be a common symptom
of gallbladder dysfunction.
of Common Bile Duct Stones (Choledocholithiasis)
in the common bile duct ( choledocholithiasis) can
cause somewhat different symptoms:
As with acute
cholecystitis, these are symptoms that indicate an emergency situation.
- If they
block the flow of bile, they can cause jaundice (yellowish skin).
- If they
cause infection in the bile duct (called cholangitis),
symptoms may include fever, chills, nausea and vomiting, and
severe pain in the upper-right quadrant of the abdomen.
may become rapid and blood pressure may drop abruptly.
SERIOUS ARE GALLSTONES AND GALLBLADDER DISEASE?
gallstones seldom lead to problems. Death from even symptomatic
gallstones is very rare, accounting for only 0.2% of annual deaths
in the United States. Serious complications are rare and, if they
occur, usually develop from stones in the bile duct or after surgery.
of Acute Cholecystitis (Gallbladder Inflammation)
The most serious
complication of acute cholecystitis is infection that spreads to
other parts of the body ( septicemia). This can be life threatening.
Symptoms include fever, rapid heartbeat, fast breathing, and mental
Among the conditions that can lead to septicemia are the following:
and empyema require prompt surgery. This complications can be avoided,
however, by seeing a physician as soon as gallbladder symptoms occur.
or Abscesses. If acute cholecystitis is untreated and becomes
very severe, inflammation can cause abscesses or destroy enough
tissue in the gallbladder (called necrosis) to
Gallbladder. About 1% to 2% of persons with acute cholecystitis
have a perforated gallbladder, which is a life-threatening condition.
The risk for perforation increases with a condition called
emphysematous cholecystitis , in which gas forms in
the gallbladder. This condition is most common in people with
Pus in the gallbladder (called empyema) occurs in 2% to 3% of
patients with acute cholecystitis. Abdominal pain is usually
severe and is typically present for more than seven days. The
physical exam is not distinctive. The condition can be life
threatening, particularly if the infection spreads to other
parts of the body.
from Choledocholithiasis (Stones in the Common Bile Duct)
lodge in the common bile duct ( choledocholithiasis)
instead of the gallbladder, serious complications can occur.
Infection in the Common Bile Duct (Cholangitis). Infection
in the common bile duct ( cholangitis) from obstruction
is common and serious. Those at highest risk for a poor outlook
also have one or more of the following conditions:
are administered immediately, the infection clears up in 75% of
patients. If cholangitis does not improve, the infection may spread
and become life threatening. Either surgery or a procedure known
as endoscopic sphincterotomy is required to open and drain the ducts.
- Age over
Pancreatitis. Choledocholithiasis is responsible for most
cases of pancreatitis (inflammation of the pancreas),
a condition that can be life threatening. The pancreatic duct, which
carries digestive enzymes, joins the common bile duct right before
it enters the intestine. It is therefore not unusual for stones
that pass through or lodge in the lower portion of the common bile
duct to obstruct the pancreatic duct.
Cancer and Porcelain Gallbladders
present in about 80% of people with gallbladder cancer. This cancer
is very rare, however, even among people with gallstones. The exception
is in people with so-called porcelain gallbladders, who have a very
high risk for cancer. (In this condition, the gallbladder walls
have become so calcified that they look like porcelain on an x-ray.)
Whether gallstones themselves cause the cancer, or whether some
factor in bile is responsible for both conditions is unknown. One
study demonstrated that gallbladder removal reduced the likelihood
of bile duct cancer, suggesting that gallstones themselves were
GETS GALLSTONES AND GALLBLADDER DISEASE?
Between 10% and
20% of all adults over 40 have gallstones. (Only 1% to 3% of the
population, however, complains of symptoms during the course of
Factors in Women
Women are much
more likely than men to develop gallstones. They occur in nearly
25% of women in the US by age 60 and up to 50% by age 75. (Again,
in most cases they are asymptomatic.) In general, women are probably
at increased risk because estrogen stimulates the liver to remove
more cholesterol from blood and divert it into the bile.
Pregnancy. Pregnancy increases the risk for gallstones, although
they may disappear after delivery. Pregnant women with stones are
more likely to have symptoms than nonpregnant women.
Hormone Replacement Therapy. Women taking hormone replacement
therapy are at higher risk for gallstones. Estrogen administered
through the patch may pose a lower risk than oral estrogen. One
study suggested, however, that oral and patch forms of estrogen
replacement therapy pose equal risks for cholesterol supersaturation
and therefore gallstone formation. In any case, oral estrogen has
a greater effect on the liver itself and raises triglycerides, a
fatty acid that increases the risk for cholesterol stones. Postmenopausal
women at high risk for both gallstones and disorders related to
estrogen loss may want to check with their physicians for alternatives
to hormone replacement therapy. (There appears to be a very low
or no risk with low-dose oral contraceptive in premenopausal women.)
[ See the Report #40, Menopause, Estrogen
Loss, and Their Treatments. ]
Factors in Men
About 20% of
men have gallstones by the time they reach 75 years of age. Because
most cases are asymptomatic, however, the rates may be underestimated
in elderly men. One study of nursing home residents reported that
66% of the women and 51% of the men had gallstones. Men who have
their gallbladders removed, moreover, are more likely to have severe
disease and operative complications than women.
is relatively rare in children. When they occur they are more likely
to be pigmented stones. Girls do not seem to be more at risk than
boys are. The following conditions may put children at higher risk:
of abdominal surgery.
Northern Europeans have a higher risk for gallstones than people
of Asian and African descent do. (People of Asian descent who develop
gallstones are most likely to have the pigment type.) Native Americans,
particularly Pima Indians, are especially prone to developing gallstones.
Pima women, in fact, have an 80% chance of developing gallstones
during their lives. (It should be noted, however, that the Pima
tribe has a very high incidence of obesity and diabetes, which are
both related to gallstones.)
People with diabetes
are at higher risk for gallstones and have a higher than average
risk for acalculous gallbladder disease (without stones). Gallbladder
disease may progress more rapidly in patients with diabetes, who
tend to suffer worse infections in general.
and Weight Changes
Being overweight is a significant risk factor for gallstones. In
such cases, the liver over-produces cholesterol which is delivered
into the bile and causes it to become supersaturated. Some evidence
suggests that specific dietary factors (saturated fats and refined
sugars) are the primary culprit in these cases, although studies
are conflicting. Animal studies, however, suggest that obesity itself,
not any particular foods, triggers the process leading to cholesterol
supersaturation and the formation of stones.
Weight Cycling. Rapid weight loss or cycling (dieting and
then putting back weight) further increases cholesterol production
in the liver, with resulting supersaturation and risk for gallstones.
A 2000 study suggested the following rates for gallstones related
to extreme and rapid weight loss:
of gallstone cases in these situations are symptomatic. The risk
for gallstones are highest in the following dieters:
- The risk
for gallstones as high as 12% after eight to 16 weeks of restricted
- The risk
is more than 30% within a year to 18 months after gastric by-pass
also puts people at risk for gallstones. For example, a 16-year
study found that the risk for gallstone surgery was 68% higher for
women who lost and then regained more than 20 pounds at least once
than in women whose weight remained stable.
who lost more than 24% of their initial body weight.
who lose more than 1.5 kg (3.3. lb.) a week.
on very low-fat, low-calorie diets.
and Cholesterol-Lowering Drugs
does not correlate with overall cholesterol levels, but persons
with low HDL cholesterol (the so-called good cholesterol) levels
or high triglyceride levels are at increased risk for stones. In
fact, the cholesterol- lowering drugs gemfibrozil (Lopid)
and clofibrate (Atromid-S) reduce cholesterol levels in the blood
by increasing the amount secreted into the bile, thus creating a
higher risk for gallstones. (Other cholesterol-lowering agents
do not have this effect.) [
Intravenous Feeding. Prolonged intravenous feeding reduces
the flow of bile and increases the risk for gallstones.
Cirrhosis. Cirrhosis poses a major risk for gallstones, particularly
Diuretics. In addition to the cholesterol-lowering drugs
mentioned above, thiazide diuretics may slightly increase the risk
Blood Disorders. Chronic hemolytic anemia, including sickle
cell anemia, increases the risk for pigment gallstones.
CAN GALLSTONES AND GALLBLADDER DISEASE BE PREVENTED?
Some studies have suggested that certain dietary factors may
Gallstones during Weight Loss. Maintaining a normal weight
and avoiding rapid weight loss are the keys to reducing the risk
of gallstones. Taking ursodiol or ursodeoxycholic acid (Actigall)
during weight loss may reduce the risk for people who are very overweight
and need to lose weight quickly. These agents are ordinarily used
to dissolve existing gallstones. It should be noted, however, that
this medication is very expensive. Of note is a 2001 study which
suggested that orlistat (Xenical), an agent approved for treating
obesity, may protect against gallstone formation during weight loss.
The drug appears to reduce bile acids and other components involved
in gallstone production. [ See Non-Surgical Therapy for Gallstones
under What Are the Treatments for Gallstones?, below.]
should reduce their intake of saturated fats, and especially
people at risk for gallbladder disease. Some studies, however,
have found an association between a lower risk for gallstones
in people who consumed foods containing monounsaturated fats
(found in olive and canola oils).
of fiber has been associated with a lower risk for gallstones.
is a fat known as a phospholipid, which is known to help prevent
the formation of cholesterol gallstones. Dietary lecithin is
available in health food stores and is found in eggs, soybeans,
liver, wheat germ, and peanuts. Animal studies have suggested
that soy and buckwheat protein may protect against gallstones:
in one such study, buckwheat offered more protection than soy.
There is no evidence that lecithin supplements or foods containing
it can prevent gallstones in humans.
of sugar has been associated with an increased risk for
in small amounts (one ounce per day) has been found to reduce
the risk in women by 20%. It should be stressed that alcohol
is easily abused, and higher amounts may increase the risk of
many diseases, including breast cancer, in women.
acid (vitamin C) appears to help break cholesterol down in bile.
Vitamin C deficiencies have been associated with a higher risk
for gallstones. One 2000 study, which confirmed some previous
ones, reported that supplements were associated with a reduced
risk for gallbladder disease in women. (Vitamin C had no effect
one way or the other in men.)
- In one
study, men who drank two or more cups of regular coffee daily
(either instant, filtered, or espresso) had a 40% lower risk
of developing the disease over ten years than did the men who
did not drink coffee regularly. Those who drank more than four
cups had the lowest risk. The benefits and risks of caffeine
consumption vary depending on the individual's health, so high
consumption of coffee to prevent gallstones is not recommended
as a general preventive measure.
and vigorously may reduce the risk of gallstones and gall bladder
disease, even in people who are overweight. Studies on both men
and women are reporting a lower risk for gallstones with exercise.
One study indicated that men who performed endurance-type exercise
(such as jogging and running, racquet sports, and brisk walking)
for thirty minutes five times per week reduced their risk for gallbladder
disease by up to 34%. The benefit depended more on the intensity
of activity than the type of exercise. A 1999 study on women reported
that exercise reduced gallstone risk regardless of whether women
lost weight or not. Some researchers guess that in addition to controlling
weight, exercise helps normalize blood sugar levels and insulin
levels, which, if abnormal, may contribute to gallstones.
Some data had
indicated that taking nonsteroidal anti-inflammatory drugs (NSAIDs),
such as aspirin or ibuprofen, protects against the development of
gallstones. A recent study of more than 400 chronic arthritis sufferers
who took NSAIDs regularly, however, reported no significant protection.
ARE GALLSTONES AND GALLBLADDER DISEASE DIAGNOSED?
challenge posed by gallstones is to be sure that abdominal pain
is caused by stones and not by some other condition. Ultrasound
or other imaging techniques usually detect gallstones readily. Nevertheless,
because gallstones are common and most cause no symptoms, simply
finding stones does not necessarily explain a patient's pain, which
may be caused by numerous other conditions.
out Other Disorders
In patients with
abdominal pain, causes other than gallstones are usually responsible
if the pain lasts less than 15 minutes, frequently comes and goes,
or is not severe enough to limit activities.
Irritable Bowel Syndrome. Irritable bowel syndrome (IBS)
has some of the same symptoms as gallbladder disease, including
difficulty digesting fatty foods. In IBS, however, pain usually
occurs in the lower abdomen.
Other Conditions with Similar Symptoms. Acute appendicitis,
inflammatory bowel disease (Crohn's disease or ulcerative colitis),
pneumonia, stomach ulcers, hiatal hernia, hepatitis, kidney stones,
urinary tract infections, diverticulosis or diverticulitis, pregnancy
complications, and even a heart attack may mimic a gallbladder attack.
A physical exam
often reveals tenderness in the upper right area of the abdomen
in acute cholecystitis and sometimes in biliary colic. There is
usually no tenderness in chronic cholecystitis.
Blood tests are
usually normal in people with simple biliary colic or chronic cholecystitis.
The following abnormalities may indicate gallstones or complications:
- The enzyme
alkaline phosphatase and bilirubin are usually elevated in acute
cholecystitis, and especially choledocholithiasis (common bile
duct stones). Bilirubin is the orange-yellow pigment found in
bile. High levels cause jaundice, which gives the skin a yellowish
enzymes known as aspartate (AST) and alanine (ALT) aminotransferase
are elevated when common bile duct stones are present. A three
fold or more increase in ALT strongly suggests pancreatitis.
- A high
white blood cell count is a common finding in many (but not
all) patients with cholecystitis.
Techniques for Diagnosing Gallstones and Infection (Cholecystitis)
Ultrasound, the diagnostic method most frequently used to detect
gallstones, is a simple, rapid, and noninvasive imaging technique.
not as useful for common bile duct stones and cannot image the cystic
duct. According to one 2000 study, ultrasound is not useful for
identifying cholecystitis in patients who do not have gallstones
but have fever and abdominal pain. In this study, ultrasound detected
some gallbladder abnormalities, no matter what the cause of the
abdominal pain. In only a few cases were the symptoms actually caused
- The patient
must not eat for six or more hours before the test, which takes
only about 15 minutes.
detects gallstones as small as two millimeters in diameter with
an accuracy of 90% to 95%.
the same procedure, the physician can check the liver, bile
ducts, and pancreas and quickly scan the gallbladder wall for
thickening (characteristic of cholecystitis). Air in the gallbladder
wall may indicate gangrene.
Cholescintigraphy. Cholescintigraphy, a nuclear imaging technique,
is noninvasive and useful if ultrasound does not reveal cholecystitis
but the condition is still suspected because of biliary pain. Cholescintigraphy
can take one to two hours and even longer. The procedure involves
the following steps:
the scan gives false positive results, particularly in alcoholic
patients with liver disease or patients who are fasting or receiving
all nutrients intravenously.
- A tiny
amount of a radioactive dye is injected intravenously. This
material is excreted into bile.
- A camera
detects the dye as it passes from the liver into the gallbladder.
- If the
dye does not enter the gallbladder, a gallstone may be obstructing
the cystic duct, indicating acute cholecystitis. (The scan,
however, cannot identify individual gallstones. Nor can it detect
Oral Cholecystography. Oral cholecystography uses a tablet
containing a dye that is employed during an x-ray. It is useful
for determining the structural and functional status of the gallbladder,
often before nonsurgical procedures.
- The patient
eats a meal containing fat at noon the day before the test and
a fat-free meal that evening. After the evening meal, the patient
can not eat and can only drink water.
- The patient
takes a number of tablets at five minute intervals three hours
after the last meal the night before the procedure.
- The dye
is absorbed by the intestine, excreted by the liver, and concentrated
in the gallbladder.
- The following
day, the patient is x-rayed.
are outlined on the x-ray by the dye.
Common Bile Duct Stones (Choledocholithiasis)
common bile duct stones is a complicated process. It requires blood
tests, imaging tests, and invasive procedures that serve both for
detection and removal. If there is evidence for common bile duct
stones, such as dark urine, jaundice, pancreatitis, or elevated
liver function tests, then other tests are required.
Laboratory Tests. The following are elevated on blood tests:
- The enzyme
(orange-yellow pigment found in bile).
enzymes known as aspartate (AST) and alanine (ALT) aminotransferase.
Even when noninvasive tests suggest common duct stones, only
about 20% to 30% of patients actually have them. For a definite
diagnosis, invasive procedures that serve for both detection and
stone removal are required. The standard test in such cases is endoscopic
retrograde cholangiopancreatography (ERCP). [For a description of
ERCP see How Are Common Bile Duct Stones (Choledocholithiasis)
Ultrasound (EUS). Standard ultrasound is useful for the
diagnosis of gallstones, but it is not as sensitive for identifying
common bile duct stones, particularly in obese patients or when
intestinal gas is present. (Normal ultrasound results along
with normal bilirubin and liver enzyme tests, however, are very
accurate indications that no problems are present.) A variation
called endoscopic ultrasound (EUS), however, may prove to be
accurate for this purpose and even eventually serve as an alternative
to ERCP. One 2000 study suggested that this technique may also
be useful for detecting stones in pancreatitis when the cause
Resonance Cholangiography. Magnetic resonance imaging (MRI)
techniques, particularly one called magnetic resonance cholangiography
(MRC), are proving to be very effective in detecting common
bile duct stones. Experts hope that eventually MRC will replace
endoscopic retrograde cholangiopancreatography (ERCP), an invasive
technique. ERCP is now used for both diagnosing and removing
common duct stones. Studies in 2001 suggest, however, that MRC
would eliminate the need for ERCP in only a small number of
patients. [ See below. ] MRC is extremely sensitive in
detecting biliary tract cancer. This imaging procedure is very
expensive, however, and may not detect very small stones or
chronic infections in the pancreas or bile duct.
Computed Tomography. A technique known as helical, or spiral,
computed tomography (CT) scanning is showing promise. With this
process, the patient lies on a table that moves while a donut-like,
low-radiation x-ray tube rotates around the patient. It shortens
the time that a standard CT scan takes and obtains clearer images.
One 2001 study suggested that findings in the following patients
may suggest a higher risk for common duct stones and therefore the
need for invasive tests:
recommend waiting 24 to 48 hours to see if the stones pass before
performing these tests.
ultrasound tests in patients under 71 years old.
bilirubin levels in patients older than 70 years old.
It is sometimes
difficult to differentiate between pancreatitis and acute cholecystitis,
but a correct diagnosis is critical since treatment is very different.
About 40% of pancreatitis cases are associated with gallstones.
The risk for gallstone-associated pancreatitis is highest in older
Caucasian and Hispanic women. About 25% of pancreatitis cases are
severe, and this rate is much higher in people who are obese.
Blood Tests. Blood tests showing high levels of pancreatic
enzymes (amylase and lipase) can usually indicate the diagnosis
of pancreatitis. Elevated levels of alanine aminotransferase are
very specific in identifying gallstone pancreatitis.
Imaging Tests. Imaging techniques are useful in confirming
a diagnosis. Ultrasound is often used. A computed tomography (CT)
scan, along with a number of laboratory tests, can determine the
severity of the condition.
IS THE GENERAL APPROACH FOR TREATING GALLSTONES AND GALLBLADDER
Acute pain from
gallstones and gallbladder disease is usually treated in the hospital,
where diagnostic procedures are performed to rule out other conditions
and complications. There are three approaches to gallstone treatment:
removal of the stones.
removal of the gallbladder.
the American College of Physicians state that when a person has
no symptoms, the risks of both surgical and nonsurgical treatment
for gallstones outweigh the benefits. Experts suggest a wait-and-see
approach for such patients, which they have termed expectant management.
Exceptions to this policy are those at risk for complications from
gallstones, including the following:
One study reported
that very small gallstones increase the risk for acute pancreatitis,
a serious condition. Some experts therefore believe that gallstones
smaller than five millimeters warrant immediate surgery.
at risk for gallbladder cancer (such as those with calcified
- Pima Native
with stones larger than three centimeters.
who have large polyps on the gallbladder.
There are some minor risks with expectant management for asymptomatic
or low-risk individuals. Gallstones almost never spontaneously disappear,
except sometimes when they are formed under special circumstances,
such as pregnancy or sudden weight loss. At some point, then, the
stones may cause pain, complications, or both, and require treatment.
Some studies suggest that the patient's age at diagnosis may be
a factor in the possibility of future surgery. The probabilities
are as follows:
- 30% for
people diagnosed at 30 years old. (The slight risk of developing
gallbladder cancer might encourage young adults who are asymptomatic
to have their gallbladders removed.)
- 20% at
50 years old.
- 15% at
70 years old.
for Patients with Symptoms
the most common cause for hospital admissions of patients with severe
abdominal pain. The approach to patients who come to the hospital
with emergency symptoms suggesting gallstones (ie, steady and severe
pain on the right) may be the following:
The patient is
given diagnostic tests. Depending on results, the approach may be
of intravenous fluids and pain killers, usually meperidine (Demerol).
(Some physicians believe morphine should be avoided for gallbladder
to stop vomiting.
for 12 to 24 hours. These may be given to patients with evidence
of infection (acute cholecystitis), including fever or an elevated
white blood cell count.
Normal Test Results and no Severe Pain or Complications. If
the patient has no fever or underlying serious medical problems
and shows no signs of severe pain or complications, and if laboratory
tests are normal, then the patients may be discharged with oral
antibiotics and pain relievers.
Tests that Show Gallstones and Presence of Pain but no Infection.
Patients with pain and tests that indicate gallstones, but
who do not show signs of infection have the following options:
Gallbladder Infection (Acute Cholecystitis). If tests indicate
acute gallbladder infection, early gallbladder removal is often
warranted. It is usually performed at least 48 hours after admission
when inflammation has improved. Some patients can wait longer.
- They may
electively choose to have the gallbladder removed (called cholecystectomy)
at their convenience. The most common procedure is now laparoscopy,
a less invasive technique than open cholecystectomy.
- A minority
of such patients may be candidates for a stone-breaking technique
called lithotripsy (The treatment works best on solitary stones
that are less than two centimeters in diameter.)
- Drug therapy
for gallstones is available for some patients who are unwilling
to undergo surgery or who have serious medical problems that
increase the risks of surgery. Nonsurgical treatment, however,
usually cannot be used for patients who have acute gallbladder
inflammation or common bile duct stones since delaying or avoiding
surgery could be very hazardous in these cases. Recurrence rates
are high with non-surgical options. The introduction of laparoscopic
cholecystectomy has greatly reduced the use of non-surgical
Tests Showing Gallstone-Associate Pancreatitis. Patients
who have developed gallstone-associate pancreatitis almost always
require surgery, either laparoscopic or open cholecystectomy.
Tests Suggesting Common Duct Stones. If noninvasive diagnostic
tests suggest obstruction from common duct stones, the patient is
given endoscopic retrograde cholangiopancreatography (ERCP) for
confirming the diagnosis and for removing the stones. This technique
is used urgently along with antibiotics if infection is present
in the common duct (cholangitis).
ARE THE MEDICATIONS USED FOR GALLSTONES?
therapy uses bile acids in pill form to dissolve gallstones and
may be used in conjunction with lithotripsy. [ See below.]
Ursodiol or ursodeoxycholic acid (Actigall) and chenodiol (Chenix)
are the standard oral bile acid drugs used for dissolution. Most
physicians prefer ursodeoxycholic acid, which is considered to be
among the safest of common drugs and does not seem to have significant
side effects. Long-term treatment appears to notably reduce the
risk of biliary pain and acute cholecystitis. The treatment is only
moderately effective, however, since gallstones recur in the majority
Appropriate Candidates. Patients most likely to benefit
from oral dissolution therapy are the following:
probably will not benefit from this treatment are the following:
with small stones (less than 1.5 cm in diameter) with high cholesterol
Only about 30%
of patients, in fact, are candidates for oral dissolution therapy,
and the number may be much lower, since compliance is often a problem.
The treatment can take up to two years and can cost thousands of
dollars per year.
that have gallstones that are calcified or composed of bile
therapy requires the injection of the organic solvent methyl tert-butyl
ether (MTBE) into the gallbladder to dissolve gallstones. This is
a somewhat technically difficult and hazardous procedure and should
be performed only by experienced physicians in hospitals where research
on this treatment is being done. Preliminary studies indicate that
MTBE rapidly dissolves stones. The ether remains liquid at body
temperature and dissolves gallstones within five to twelve hours.
Serious side effects include severe burning pain.
IS EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY USED FOR GALLSTONES?
by extracorporeal shock wave lithotripsy (ESWL) may be an appropriate
therapy for some patients who cannot undergo surgery. The treatment
works best on solitary stones that are less than two centimeters
in diameter. Less than 15% of patients are good candidates for lithotripsy.
The typical procedure is as follows:
A 2000 study
compared the ability of different shock wave lithotripsy machines
to fragment gallstones. The HM3, Modulith SLX, and Lithostar C machines
had the best record for breaking stones into the smallest fragments.
The use of lasers for lithotripsy is under investigation.
- The patient
typically sits in a tub of water.
ultrasound shock waves are directed through the abdominal wall
toward the stones.
- The shock
waves travel through the soft tissues of the body and break
up the stones.
- The stone
fragments are then usually small enough to be passed through
the bile duct and into the intestines.
is generally combined with bile acid treatment to help dissolve
the fragmented pieces of the original gallstone.
mortality rate for lithotripsy is essentially zero, complications
include pain in the gallbladder area and pancreatitis, usually occurring
within a month of treatment. In addition, not all of the fragments
may clear the bile duct. Adding erythromycin to the treatment regimen
may help remove these fragments. About 35% of patients who are left
with fragments are at risk for further problems, some severe. The
chance of recurrence is high with this procedure, and in one study,
45% of patients eventually required surgery.
ARE THE SURGICAL PROCEDURES FOR GALLSTONES AND GALLBLADDER DISEASE?
Considerations for Gallbladder Removal (Cholecystectomy)
Every year, about
500,000 people have their gallbladders removed. The gallbladder
is not an essential organ, and even today, only surgical removal
of the gallbladder ( cholecystectomy) guarantees that
the patient will not suffer a recurrence of gallstones. This is
one of the most common surgical procedures performed on women and
can even be performed on pregnant women with low risk to the baby
and mother. The primary advantages of surgical removal of the gallbladder
over nonsurgical treatment are both the elimination of gallstones
and also the prevention of gallbladder cancer.
Appropriate Surgical Candidates. Candidates for surgery
often have one of the following conditions:
Surgery. Cholecystectomy may be performed within several days
of hospitalization for an acute attack. Some patients can be safely
discharged after treatment of an attack of acute cholecystitis and
undergo elective surgery several months later.
- One very
severe gallstone attack.
less severe gallstone attacks.
General Outlook. Although cholecystectomy is very safe,
as with any operation, there are risks of complications depending
on whether the procedure is elective or an emergency procedure.
Effects of Gallbladder Removal. Although removal of the gallbladder
has not been known to cause any long-term adverse effects aside
from occasional diarrhea, some researchers have been concerned about
its effects on the body's cholesterol levels. One study found that
within three days of the operation, levels of total cholesterol
and LDL returned to their preoperative levels. After three years,
however, some types of cholesterol not ordinarily associated with
coronary artery disease had risen significantly. These results did
not necessarily indicate any increased risk for coronary artery
disease, but they did show that the metabolism of cholesterol by
the liver had been altered. People who have had their gallbladders
removed should have their cholesterol levels checked periodically,
as should every adult. Short-term treatment with cholesterol-lowering
drugs containing HMG-CoA reductase inhibitors, commonly known as
statins, such as pravastatin (Pravachol), appears to lower cholesterol
levels in surgical patients.
- When cholecystectomy
is performed as elective surgery, the mortality rates are very
low. (Even in the elderly, mortality rates are only between
0.7% to 2%).
cholecystectomy carries a much higher mortality rate (as high
19% in ill elderly patients).
Procedures versus Laparoscopy
Until the early
1990s, open cholecystectomy (the removal of the gallbladder through
an abdominal incision) was the standard treatment. Now, laparoscopic
cholecystectomy (commonly called lap choly ), which
uses small incisions, is the most commonly used surgical approach.
First performed in 1987, laparoscopy is now used in nearly 75% of
all cholecystectomies in the United States. Because of the appeal
of laparoscopy, gallstone operations have increased by as much 40%
in some parts of the country. Of concern is a significant increase
in its use by patients who have inflammation in the gallbladder
but no gallstones and in those who have gallstones but no symptoms.
Advantages of Laparoscopy. Laparoscopy has some significant
advantages over open cholecystectomy:
of Open Cholecystectomy. Some experts believe, however, that
the open procedure has a number of advantages compared to laparoscopy:
- The patients
can leave the hospital and resume normal activities earlier
than with open surgery.
- The incisions
are small, and there is less post-operative pain and disability
than with the open procedure.
has fewer complications.
- One study
reported that although the treatment cost of laparoscopy was
higher than the open procedure, the more rapid recovery with
laparoscopy translated into fewer sick days and so a greater
reduction in overall costs.
- It is
faster to perform.
- It poses
less of a risk for bile duct injury, which occurs in only 0.1%
to 0.2% of open procedures. (It has more overall complications
than laparoscopy, however.)
Candidates for Laparoscopy or Open Cholecystectomy
Treatment of choice for most adult patients, with or without
symptoms, who have chosen to have their gallbladders removed.
Patients who have had extensive previous abdominal surgery.
Overweight patients (as long as abdominal wall is not excessively
Patients with complications of acute cholecystitis (empyema,
gangrene, perforation of the gallbladder).
Patients with acute cholecystitis. (About 5% to 20% will need
to convert to open surgery.)
Elderly patients. (Those over 80 are particularly likely to
have lower complication rates from open cholecystectomy than
Patients with acalculous gallbladder disease (without stones).
Seriously ill patients with acute cholecystitis who do not
respond to fluid aspiration (percutaneous cholecystostomy).
Possible candidates with very experienced surgeons):
Patients with acute gallstone pancreatitis that has subsided.
Patients with prior surgery in the upper abdomen.
Pregnant women with symptomatic gallstone.
With laparoscopy, removal of the gallbladder is typically performed
for Conversion from Laparoscopy to an Open Procedure. In about
5% to 10% of laparoscopies, conversion to open cholecystectomy is
required during the procedure. Some reasons for conversion to open
surgery include the following:
cholecystectomy requires general anesthesia, although it is
now mostly done as outpatient surgery. (One study suggested
that 24-hour monitoring afterward was not necessary and the
patient could go home the same day.)
- The surgeon
inserts a needle through the navel and pumps carbon dioxide
gas through it and into the abdomen to create space in the abdomen.
(Of note, a 2000 study recommended using a gasless procedure
for elderly patients. Such patients are more likely to require
a longer operating time, and the on-going pressure from the
carbon dioxide increases the risk for problems that require
conversion to an open procedure.)
incisions, one or two 10 to 12 mm (around half an inch) and
three 5 mm (.20 inches), are made in the abdomen .
- The surgeon
inserts a laparoscope (a thin telescope) which contains a small
surgical instrument and a tiny camera that relays an image to
a video monitor.
- The surgeon
separates the gallbladder from the liver and other areas and
removes it through one of the incisions.
and Side Effects of Surgery. Complications include the following:
or known injury to major blood vessels.
structures not clearly visible.
problems that cannot be corrected with laparoscopy.
bile duct stones that cannot be removed with laparoscopy or
not be shy about inquiring into the number of laparoscopies the
surgeon has performed. (It should not be fewer than 30.)
is a relatively high incidence of nausea and vomiting after
laparoscopic cholecystectomy, which can be treated with injections
of metoclopramide. Preoperative anti-nausea agents, such as
granisetron, may prevent these effects.
to the bile duct. (This can lead to liver damage and is the
most serious complication of laparoscopy. It is more common
with laparoscopy than with the open procedure.)
- In about
6% of procedures, the surgeon misses gallstones or they are
spilled and remain in the abdominal cavity. In a small percentage
of these cases, the stones cause obstruction, abscesses, or
fistulas (small channels) that require open surgery.
- As with
all surgeries, there is a risk for infection, but it is very
the standard surgical treatment for gallstones was open cholecystectomy
(surgical removal of the gallbladder through an abdominal incision),
which requires a wide incision and leaves a larger surgical scar.
The patient usually needs to stay in the hospital for five to seven
days and may not return to work for a month. Complications include
bleeding, infections, and injury to the common bile duct. The risks
of this procedure increase with other factors, such as the age of
the patient or if the surgeon needs to explore the common bile duct
for stones at the same time.
use even fewer and smaller incisions than laparoscopy are being
developed. There are many variations including those referred to
as twin-port, mini-site, or mini or micro-laparoscopic surgeries.
These procedures make even fewer incisions (two to three) and smaller
ones (1.2 to 3 mm or .04 to .12 in.). It should be noted, however,
that these procedures still require one large incision (10 to 12
mm or about half an inch). They are still investigative and have
are also not proven. Although such surgeries are proving to be feasible
in cases unlikely to have complications, studies are mixed on whether
they reduce postoperative pain or improve recovery time beyond that
of standard laparoscopy.
- They employ
fiberoptics to view the surgical areas that are less bright
than those used with conventional laparoscopy.
- The instruments
are very fragile.
- The field
of vision is very limited.
for Patients with Very Severe Infection (Cholecystitis)
cholecystostomy. Percutaneous cholecystostomy is a procedure
that may be used in seriously ill patients with severe gallbladder
infection who cannot tolerate immediate surgery. This procedure
uses a needle to withdraw (aspirate) fluid from the gallbladder.
A drainage catheter is inserted through the skin and into the gallbladder
for about six to eight weeks while the fluid drains out. After that
time, if possible, laparoscopy or an open cholecystectomy may be
Gallbladder Aspiration. With this procedure, fluid is aspirated
in one procedure while the gallbladder is viewed using ultrasound.
It does not require an indwelling catheter afterward and may have
fewer complications than percutaneous cholecystostomy.
ARE COMMON BILE DUCT STONES (CHOLEDOCHOLITHIASIS) MANAGED?
Common duct stones
are suspected during cholecystectomy in 10% to 15% of patients.
Historically, the approach to managing common duct stones (choledocholithiasis)
has been the following:
- In the
past, when common bile duct stones were suspected, the approach
was open surgery (open cholecystectomy) and surgical exploration
of the common bile duct.
- Now endoscopic
retrograde cholangiopancreatography (ERCP) with endoscopic
sphincterotomy (ES) are the most frequently used procedures
for detecting and managing common duct stones. The procedure
involves the use of an endoscope (a flexible telescope containing
a miniature camera and other instruments), which is passed through
the mouth and down to the bile duct entrance. [ See Below.
cholecystectomy is increasingly being used for detection and
removal of common duct stones. In such cases, it is used in
combination with ultrasound or a cholangiogram (an imaging technique
that uses a dye injected into the bile duct and x-rays to view
any stones.) How and when to use this technique for common duct
stones, however, is currently under debate. [ See Below.
Retrograde Cholangiopancreatography (ERCP) with Endoscopic Sphincterotomy
The ERCP and
ES Procedure. A typical ERCP and endoscopy sphincterotomy (ES)
procedure includes the following steps:
with ES is Used.
- The patient
is given a sedative and is told lie on his or her left side.
- An endoscope
(a tube containing fiberoptics connected to a camera) is passed
through the mouth and stomach and into the duodenum (top part
of the small intestine) until it reaches the point where the
common bile duct enters. This does not interfere with breathing,
but the patient may have a bloating sensation.
- A thin
catherter is then passed through the endoscope.
material (a dye) is injected through the catherter into the
opening of the duct. The dye allows visualization using an x-ray
of the biliary tree (the system of ducts through which bile
flows, including the common bile duct) and any stones contained
in the area.
may also be passed through the endoscope to remove any stones
that are detected.
- A tiny
incision is usually made in the orifice of the common bile duct
and through the muscles that enclose the lower common bile duct
(called the sphincter of Oddi). This serves to widen the junction
between the common bile duct and intestine (called the ampulla
of Vater ) so that the stones can be extracted more easily.
This part of the procedure is the endoscopic sphincterotomy
(ES). (It is also sometimes referred to as papillotomy,
although this is a slightly different variation.)
- One recent
alternative to ES is the use of a small inflatable balloon (called
endoscopic balloon dilation) that opens up the ampulla of Vater
to allow stones to pass and so avoid cutting the muscles.
- Once the
junction has been opened, the stones may pass out on their own
or they may be extracted with the use of tiny baskets or balloons.
- This procedure
is usually followed by later cholecystectomy (removal of the
gallbladder) to eliminate the source of the stones. [See What
Are the Surgical Procedures for Gallstones and Gallbladder Disease?.]
Complications of ERCP and endoscopy sphincterotomy occur in
up to 10% of cases and can be serious, with mortality rates of about
0.5%. They range from mild to severe and include the following:
- When stones
are detected prior to gallbladder removal (open or laparoscopic
- When stones
are found in the common duct after cholecystectomy.
ERCP plus antibiotics for patients with gallstone cholangitis
(serious infection in the common bile duct).
- For acute
pancreatitis caused by gallstones. (Urgent ERCP for this condition,
compared to conservative treatment, has been controversial.
One study reported that only patients who had infection and
persistent obstruction in the ducts benefited from urgent intervention.
A 2000 analysis of four other studies, however, reported that
ERCP with ES significantly improved survival rates and reduced
ERCP and endoscopic
sphincterotomy are difficult procedures and patients must be certain
their physician is experienced with them, ideally having performed
at least 180 ERCPs. Under such circumstances, ERCP can usually be
performed successfully even in critically ill patients on mechanical
(inflammation of the pancreas). (This condition occurs in 5%
of cases and can become life threatening. Younger adults are
at higher risk than the elderly. The use of the drug gabexate
may lower the risk.)
Infection. (Antibiotics may be given before the procedure to
prevent infection, although one study reported that they had
(Occurs in 2% of cases. Increased risk in patients taking anti-clotting
drugs and those who have cholangitis. This is treated by flushing
complications include stone recurrence and abscesses.
Cholecystectomy and Cholangiography for Detection and Removal
of Common Duct Stones
now increasingly using laparoscopic cholecystectomy plus an imaging
technique called cholangiography instead of ERCP when common duct
stones are suspected. The laparoscopic procedure for common duct
stones is generally as follows.
Experts are debating
the choice of laparoscopy and cholangiography as an alternative
to preoperative ERCP for detecting and managing common duct stones.
Many surgeons believe that laparoscopy is becoming safe and effective
and should be the first choice. They recommend ERCP only for high-risk
cases (eg, gallstone-caused pancreatitis, infection in the duct,
and patients who cannot take general anesthesia). Still, laparoscopy
for common duct stones should be performed only by surgeons experienced
in this new and demanding technique.
are made as they would be in laparoscopic cholecystectomy. [
See the description under What Are the Surgical
Procedures for Gallstones and Gallbladder Disease? .]
- A tiny
opening is made in the cystic duct which connects the gallbladder
to the bile duct, and a thin tube is introduced to perform a
cholangiogram. (In this procedure, a dye is administered to
reveal the stone's location on x-rays.)
- If stones
are identified, the surgeon inserts a tube with an inflatable
balloon that is used to widen the duct.
are usually retrieved or withdrawn from the duct either with
the use of a balloon or with a tiny basket.
- If laparoscopy
is unsuccessful, then ERCP or open surgery is performed.
or common bile duct exploration, is used to remove large stones
or in cases when the duct anatomy is complex. In this procedure,
the physician carries out open abdominal surgery and extracts gallstones
through an incision in the common bile duct. Routinely, a so-called
T-tube is temporarily left in the common bile duct after surgery
and the physician x-rays the bile duct through the tube seven to
ten days postoperatively to determine if any stones remain in the
for Common Bile Duct Stones
Shock wave lithotripsy
is an option in certain cases for bile duct stones that cannot be
Mechanical Endoscopic Lithotripsy. Endoscopy with mechanical
lithotripsy employs a tiny steel crushing basket, which is inserted
through the endoscope and into the common bile duct. The basket
opens to trap and then crush the stone. It is capable of crushing
and removing very large stones. The overall success rate is 80%
to 90%, although 20% to 30% of patients require more than one treatment.
Extracorporeal Shock Wave Lithotripsy. Extracorporeal shock
wave lithotripsy is an option in certain cases for bile duct stones
as it is for stones in gallbladder. [ See a discussion
of ESWL under What Is the General Approach for Treating Gallstones
and Gallbladder Disease? , above. ]
ELSE CAN HELP FOR GALLSTONES AND GALLBLADDER DISEASE BE OBTAINED?
National Digestive Diseases Information Clearinghouse, NIDDK, NIH,
31 Center Drive, MSC 2560, Bethesda, MD 20892-2560, USA Call (301-654-3810)
or on the Internet (http://www.niddk.nih.gov)
American Gastroenterological Association, American Digestive Health
Foundation, 7910 Woodmont Avenue, 7th Floor, Bethesda, MD 20814.
Call (301 654-2055) or (http://www.gastro.org)
American Society for Gastrointestinal Endoscopy, 13 Elm Street,
Manchester, MA 01944-1314. Call (978-526-08330) or (http://www.asge.org/)
American College of Gastroenterology, 4900 B South 31 St., Arlington,
VA 22206. Call (703-820-7400), or (http://www.acg.gi.org/)
American Liver Foundation, 75 Maiden Lane, Suite 603, New York,
NY 10038. Call (800-GO LIVER) or (800-465-4837) or on the Internet
National voluntary organization dedicated to preventing, treating,
and curing gallbladder diseases through research and education.
Provides patient brochures, video and audio tapes.