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Gallstones

Introduction

Gallstones can create problems for many of us and yet often we do not fully understand why we are suffering pain and discomfort, and some are not quite sure what the gallbladder is.

Background: what is the gallbladder?

The gallbladder is a small sac which you will find on the right hand side of your body, just below the liver. The liver produces something called bile which is a greenish-brown coloured liquid. Often referred to as gall, this is stored and held in the gallbladder, hence the reason why this is called the ‘gallbladder’. The body carries this gall liquid into the small intestines via the bile ducts and it helps our system to deal with the digestion of food, predominantly fats. The bile ducts are narrow tubes and every time that we eat, gall passes down these tubes and into the intestines.

What are gallstones?

Problems occur when ‘gallstones’ develop within the gallbladder. These are solid, hard particles which can be small and sometimes even quite large. Sometimes the problem is caused by just one large gallstone and other times it is caused by numerous smaller stones. When we get gallstone pain, often referred to as a gallbladder attack or biliary colic, which happens because the gallstones have blocked the bile ducts or the gallbladder itself (the area referred to as the biliary tract.)

Sometimes the stones can be so small that they are not noticeable, particularly if they do not cause any pain. Often they will be identified when undergoing tests for other things such as ultrasounds for pregnancy.

There are two main types of gallstones, either formed from cholesterol or bile acid and they are formed when chemicals within the gallbladder solidify. When these particles combine with mucus in the bile we get something called biliary sludge which is most commonly made up of cholesterol crystals and calcium salts. Calcium bilirubinate and calcium carbonate can also contribute.

What causes gallstones? There can be many different causes of gallstones. Being overweight and eating a high fat diet can be one of the main factors. They can also be a side effect of sickle cell anaemia. As we age, our likelihood of suffering from gallstones also increases. Likewise, losing weight too fast can be a trigger.

Causes

So what causes gallstones? In truth, they can form due to any number of things but we will look at a few of the common possible causes.

Obesity. Being overweight can result in a high level of cholesterol building up in the bile which in turn can create cholesterol gallstones. See here for more information (hyperlink to Page URL: https://www.gastrolondon.co.uk/what -are-gallstones.html) . An unhealthy diet, high in fat and calories adds to the problem. By steadily working to lose weight by following a diet low in fat, unrefined carbohydrates and high in fibre the risk of is can be reduced.

Rapid weight loss. Surprisingly enough, rapid weight loss can also have the same effect. If we do not eat, for whatever reason, the body starts to break down fat. When this happens the liver secretes additional cholesterol into the bile. This gives perfect conditions for cholesterol gallstones to start to build up. Losing a large amount of weight can also have an effect upon the gallbladder and stop it from emptying correctly.

Intestinal diseases. Certain intestinal diseases can also contribute towards gallstone formation, for example Crohn's disease, which is an on-going inflammatory disorder affecting the gastro-intestinal tract. It is often referred to as inflammatory bowel disease. Ulcerative colitis can also help towards the formation of gallstones. This is also an inflammatory disease but it affects the large intestine and can result in bleeding and ulceration.

Metabolic syndrome, diabetes, and insulin resistance. Metabolic syndrome is linked to people who are overweight. It can also result in type 2 diabetes.

Sickle cell anaemia. With this disease, the red blood cells breakdown and produce something called bilirubin. What causes gallstones to develop here? As we have discussed previously, increased levels of bilirubin can cause the production of pigment gallstones.

Stress. Depending upon the individual, you may find that during particularly stressful times you can suffer from gallstone pain and the many symptoms that this can cause. Although it is not clearly understood why this happens, certain people definitely find that this can be a trigger.

Being female. It has been found that oestrogen actually causes the liver to take more cholesterol from the blood and convert this into bile. We have already said that cholesterol is one of the major causes of gallstones being produced.

Pregnancy also seems to exacerbate their production. If surgery is required to remove the gallstones, however, it would be delayed until after the birth, by which time they may have disappeared.

As we can see, hormones can play a big part in gallstone production so it follows that HRT (Hormone Replacement Therapy) can also vastly increase the risk of their formation. Oestrogen can also raise the level of triglycerides which is a fatty substance and which can accelerate the production of cholesterol gallstones.

Some medications can also act as triggers so do check with your doctor if you feel that your prescription medicine may be exacerbating your condition.

Although these are some of the most common causes of gallstones appearing in the gallbladder, this is not an exhaustive list. Medical science is still not certain of what the precise causes are and many of them are subjective (depending on an individuals diet etc.)

Symptoms

You may experience symptoms without realising that gallstones are the culprits. You may feel sick and nauseous or have pain in the abdomen. Pain can be so sudden and severe that it can be confused with pain caused by a heart attack. Abdominal cramps can be particularly severe if you experience something called Cholecystitis which is caused when gallstones get stuck in the cystic duct. Bile then builds up in gallbladder which stretches and gallbladder walls which in turn become inflamed and can even get infected.
Abdominal cramps.

Cramping in the abdomen can come on very quickly and suddenly or can be a gradual build-up of discomfort and pain. This can be accompanied by feelings of nausea and sickness and occasionally vomiting. This may happen for no particular reason or may be experienced after eating a very heavy or fatty meal. Triggers that affect one person may not affect another e.g. drinking coffee or tea containing caffeine can also promote an attack of abdominal cramp or feeling sick.

Biliary colic

This gallstone symptom is fairly common and is created when a gallstone blocks one of the bile ducts. The bile ducts are the tubes that carry bile. Biliary colic pain can be intermittent and come in waves, but it can also be very painful and quite extreme. If a patient has never experienced this severity of pain before, they can easily confuse it with the symptoms of a heart attack, stomach ulcer, acid reflux or IBS.

Visit our detailed page on biliary colic

Cholecystitis

This pain is due to inflammation of the gallbladder. It can be experienced at the same time as biliary colic and again, can be fairly severe when it makes its presence known. Typically, cholecystitis lasts longer than biliary colic and is associated with fever and sweating. Patients unused to this type of pain again can confuse it with many other types of pain such as from a heart attack, pneumonia, diverticular disease, appendicitis and even pancreatitis. Intravenous antibiotics are usually given to treat cholecystitis. Antibiotics are not needed for biliary colic. Doctors generally agree that after even one attack of cholecystitis, the sufferer should have their gallbladder removed.

Visit our detailed page on Cholecystitis

Passing gallstones

Thankfully, most gallstones are small in size and so can be passed out of the body naturally without any pain or discomfort. They will travel through the intestines without us even being aware of it. However, if there are a lot of stones or they are unusually large then they can get stuck in the narrow outlet where the gallbladder joins the intestines. This can lead to fairly severe and unexpected pain. If left untreated, complications can develop such as jaundice, infection in the bile (cholecystitis, cholangitis), or pancreatitis (inflammation of the pancreas).

Visit our detailed page on Passing gallstones.

Are Gallstones Symptoms always present?

Gallstones can often be present and yet cause no symptoms. Very often, they are diagnosed by accident when processes are being carried out for other reasons. A good example of this is a woman attending an ultrasound scan for pregnancy and gallstones showing up on the image.

The gallstone symptoms may also lie dormant for some time and not be felt until something happens to irritate them or trigger a reaction in the body. This may be something like eating the wrong type of food, losing a lot of weight or gaining a lot of weight. Alternatively some other medical condition may act as a precursor to gallstones being created.

Passing Gallstones

You may often hear patients refer to ‘passing gallstones’ but in truth, most of the gallstones that form in the gallbladder remain there. Very rarely they may dissolve and disappear, but this is not usual. What causes problems is when they move out of the gallbladder and into the bile ducts, which are the tubes leading from the gallbladder to the intestine. If they are small enough to pass through the body easily then there may be very little or no pain and the sufferer will not even be aware that this process is taking place. However, if there are many gallstones or they are particularly large, can get stuck in the bile ducts and block the flow of bile. This can then lead to such things as jaundice, infection in the bile (cholecystitis, cholangitis), or pancreatitis (inflammation of the pancreas).

Symptoms

Symptoms will vary and pain will depend on what effect the passing of the gallstones is having on the body.

Jaundice – This is sometimes referred to as ‘yellow jaundice’ due to the effect that it has on the colour of the patient’s skin. The eyes and skin will develop a yellowish tinge and this happens because the body cannot remove excesses of bilirubin quickly enough. We all have bilirubin in the body. It is a yellow chemical that is created when our red blood cells reach the end of their life. The body regards it as a waste product and the liver will help dispose of it. If a passing gallstone blocks the bile duct, then the bilirubin cannot reach the intestine, nor can it exit the body. Some of this yellow colour makes its way to the skin and turns it yellow. Some finds its way into the urine so the urine will become very dark yellow or brown in colour. At the same time, it cannot reach the bowels so the stool turns pale brown, cream or even white.

Cholecystitis – In most cases, cholecystitis will be created by gallstones located within the gallbladder. These cause a blockage and cause bile to build up, thus creating an infection in the gallbladder and pain for the sufferer.

Cholangitis – This again is caused by the passing gallstones as they block the bile duct which is the tube that carries bile from the liver to the gallbladder and intestines. Bile, which is created by the liver and stored in the gallbladder, will start to build up. A bacterial infection can then occur in the duct and if left untreated, this can even spread to the liver. The sufferer will become ill and experience acute pain and fever.

Pancreatitis - This is caused by an inflammation developing in the pancreas and is generally caused by one of two things: alcohol or passing gallstones. When the gallstones pass through the bile duct they can often get stuck at the place where the bile duct and the pancreatic duct open together into the duodenum. This can affect the balance of chemicals within the pancreatic duct or even block the duct completely. The result is pancreatitis. The problem occurs because enzymes secreted by the pancreas to digest food are activated in the pancreas, instead of the small intestine. When this happens, the patient will feel very ill. They will experience very severe pain and will usually require urgent medical attention.

Treatment

As can be seen, if gallstones do pass through the body, they do not always create problems but when they do, these symptoms can be severe. Diets have been put forward that are supposed to assist with the easy passing of gallstones but none of these have any medical backing and it is unlikely that they work. Self-help by the patient can assist the body to deal with gallstones by following a healthy diet and lifestyle. See our self-help page.

Gallstones already in the body will not disappear. If they do result in any of the above conditions, then the relevant treatment options will need to be followed. See our treatment pages for more details

Diagnosis

Abdominal ultrasound

This is a totally non-invasive diagnosis procedure that is pain free and used very often. The person conducting the ultrasound scan will move a sensor across your abdomen and the ultrasound will create pictures of what it can see on a video screen. The stones will show up and have typical ‘acoustic shadows’ behind them on the screen. This test can also reveal any associated problems with the gallbladder or bile ducts.

Magnetic resonance cholangiogram (MRCP)

This diagnostic test makes use of a magnetic field and pulses of radio wave energy (MRI) to give pictures of the organs and various formations within the abdomen. This is a useful tool that can locate gallstones prior to ERCP (a further test, below) or surgery and possibly help decide whether the gallbladder is being negatively affected. It can also help check the condition of the bile duct.

Visit our detailed page on Magnetic resonance cholangiogram (MRCP)

Endoscopic retrograde cholangiopancreatogram (ERCP)

This procedure is often carried out if your doctor thinks that you may have gallstones in the gallbladder or lodged in one of the bile ducts. A sedative will be used to make you sleepy. Once relaxed, the doctor will spray some local anaesthetic on the back of the throat and then gently insert a small flexible lighted tube called an endoscope down your throat. This can pass through into your stomach and allow the doctor to look at the bile ducts that help to drain your liver, gallbladder, and pancreas. If a gallstone is blocking your common bile duct, the doctor can often remove the stone by inserting small instruments through the endoscope.

Read our detailed page on Endoscopic retrograde cholangiopancreatogram (ERCP)

HIDA Scan - This is an older test which is not used as frequently as those listed above for diagnosis of gallstones. If it is used, it can show if there are any obstructions in the bile ducts due to stones. The full name for this test is a Cholescintigraphy scan but it is often called an HIDA or gallbladder scan. The doctor will inject a radioactive chemical intravenously into the patient. This chemical is then taken from the blood by the natural action of the liver and secreted into the bile. The chemical agent then follows the route of the bile and travels via the bile ducts, the gallbladder and into the intestine. A camera, placed over the abdomen, is then used by the doctor that to detect the radioactive trail of the chemical (like a Geiger counter). A picture of the liver, bile ducts and gallbladder is built up displayed. It is quite a time consuming process and can take up to 2 hrs. The name HIDA is based on the original radioactive chemical used (hydroxy iminodiacetic acid). This chemical is no longer used as there are more effective tracers.

Treatment – once a diagnosis of gallstones has been made, it is important to get the correct treatment. This might be changing your diet or surgical removal. The correct treatment requires the right diagnosis. We offer the most advanced techniques for diagnosis of gallstones. Please call us on 020 7183 7965 for a private consultation and visit our gallstones treatment page (hyperlink)

Treatment

After your examinations have been completed and the doctor diagnoses you with gallstones, he will be in a position to discuss further gallstones treatment with you, if needed.

Below is an introduction to some of the options. Click through to read more detailed pages on each treatment method.

Gallstone surgery

Your doctor may discuss surgery with you to remove your gallbladder. There are two types of surgery available:

  • Open surgery (cholecystectomy)
  • Laparoscopic cholecystectomy (keyhole surgery)

Laparoscopic cholecystectomy (keyhole surgery)

This is the most frequently method used to remove the gallbladder. Tiny cuts will be made in your abdomen whilst you are under general anaesthetic. A tiny camera and surgical instruments will then be inserted and the gallbladder removed. These cuts are so small that there is almost no scarring afterwards. If a woman wears a bikini after this type of surgery, no-one will actually realise that an operation has been done.

Open surgery (cholecystectomy)

This is the more traditional method of surgery where the gallbladder can be removed via a larger cut in your abdomen. It is more invasive than keyhole surgery and your hospital stay and recovery will be longer. Your doctor will not normally use this method unless there are reasons why the keyhole surgery cannot be conducted.

Lithotripsy (shock wave lithotripsy)

This treatment makes use of shock waves to ‘break’ the gallstones into small pieces, so that they can be dissolved with an oral bile acid pill. After effects may include biliary colic pain as the broken gallstones pass through the bile duct. It is not often used as the success rates are poor.

Read our detailed page about shock wave lithotripsy.

Gallstone dissolving agents

Special alternative treatments, potions and herbs taken to dissolve gallstones do not normally work. Something called Ursodeoxycholic Acid may also be suggested but the likelihood of any of these dissolving agents working is minimal. Ursodeoxycholic acid may need to be taken for up to two years whilst at the same time adhering very closely to a low-cholesterol diet.

Complications

Although uncommon, there are variousomplications that can occur during gallstones treatment.

Our page on gallstone treatment complications deals with the following:

  • Mirizzi syndrome - an obstruction of the common hepatic duct.
  • Choledocholithiasis relates to the presence of gallstones in the common bile duct.
  • Acute cholecystitis is an acute inflammatory disease of the gallbladder.
  • Acute obstructive cholangitis is a complex syndrome which incorporates feelings of lethargy, mental confusion and shock, as well as fever, jaundice, and abdominal pain. Created by biliary obstruction these five symptoms are often referred to as Reynolds’ Pentad.
  • Gallstone ileus is obstruction of the bowel due to blockage by one or more gallstones.

For things you can do to help-yourself, including managing your diet, visit our ‘help yourself’ section.

Help Yourself

Once you have gallstones, they are unlikely to disappear without surgery. But most of the time they will cause you few problems. Here are just a few of the things that you can do to help make them possible to live with.

Remember that most people never actually have any problems from their gallstones. For a person with gallstones diet is the key to good health.

  • Avoid Large Meals. The gallbladder empties when you eat. This helps you to digest food. As it empties, stones may become lodged and cause pain. The larger the meal, the more likely it is that a problem will occur.
  • High fibre diet. People who eat low fibre diets are at higher risk of developing problems, so it is wise to eat a high fibre diet. High fibre foods include wholemeal bread, brown rice as well as pulses (lentils, beans, peas), oats and raw or lightly cooked vegetables.
  • Low fat gallstones diet. It has been proven that diets high in fat and cholesterol and also low in fibre do a lot to irritate the gallbladder. These diets cause stones or irritate them if they are already present. Due to the role that cholesterol plays in the formation of gallstones, it is recommended to avoid food with a high content of saturated fats. This is because the body makes cholesterol from the saturated fats you eat. Foods high in saturated fats include red meat and dairy products in particular.
  • Coffee. Some studies have suggested that drinking coffee helps reduce the risk of gallstones.
  • Alcohol. Moderate intake of alcohol might also help. But, remember, do not drink more than the recommended amounts (21 units per week for men and 14 units per week for women).
  • Here are a few suggestions:

    Recommended foods to eat:

    Foods to avoid:

    Fresh fruit and vegetables

    Fried food

    Whole grains

    Highly processed food

    Lean meat, fish, poultry

    Whole milk products

    Low fat dairy products

    Fatty meat

  • Keep as fit as possible and get some exercise. If you are overweight then your gallbladder problems will be exacerbated. Gentle exercise like walking, swimming and cycling are all good. Don’t try to lose weight dramatically or too quickly as this can have the opposite effect and stir up your gallstone problems. Aim to keep everything moderate.

In addition to a sensible gallstones diet, on our next page we will have a more detailed look at some of the following self-help topics:

  • Home remedies: In addition to following a healthy diet, here you will find further Information on home remedies that may help your gallstones.
  • Herbal remedies: How they are often promoted as a healthy and effective for treatment and prevention
  • The Link between Alcohol and Gallstones: How excessive alcohol intake can indirectly lead to the formation of gallstones and possibly exacerbate existing symptoms