Conditions Gallstones

Gallstones are deposits of thickened bile fluid. They develop in the gallbladder or bile ducts. The gallbladder is a small pear-shaped hollow organ; it is located on the right-hand side of the abdomen beneath the liver. Up to a liter of bile fluid is produced in the liver every day. Bile fluid is important for the absorption of fats in the intestine. Most of it flows directly through the bile ducts into the small intestine after eating. The remaining bile fluid is stored in the gallbladder between meals and thickened.

In Germany, gallbladder surgery is among the most common operations. About 175,000 men and women are operated on every year – usually because gallstones have caused symptoms or secondary diseases.

However, gallstones are often harmless and many people remain free of pain. If discomfort occurs, only the symptoms can be treated. Sometimes an operation is considered. With this, doctors remove gallstones stuck in the bile duct or take out the entire gallbladder.

Many people have no symptoms or very few of them despite gallstones. According to studies, about 2 to 4 out of 100 people with gallstones get noticeable symptoms within one year. In about 50 out of 100 people who already had symptoms such as colic, pain recurs within two years.

With colic, bile is pushed into the intestine if the gallbladder contracts, but the exit is blocked by gallstones. The pain comes in waves and can spread to the back and right shoulder. It normally eases after an hour at most and disappears completely a few hours later. Other symptoms are also possible, such as heartburn, flatulence, nausea, vomiting, and bloating.

Bile duct stones can also trigger spasmodic epigastric pain. They can moreover cause jaundice (icterus). Jaundice can be recognized by yellowing of the skin and the whites of the eyes (sclera). The urine can also be dark and feces brightly colored.

Jaundice develops when the outflow for bile fluid remains blocked for an extended period of time. The bile pigment formed in the liver (bilirubin) – which develops when the red blood pigment hemoglobin is broken down – is then no longer able to drain out. More yellow bilirubin enters the bloodstream and this causes the discoloration.

Bile fluid consists of water and various substances some of which are not water-soluble. If these substances agglutinate, gallstones can develop. 

Most gallstones are primarily made of cholesterol. Pigment stones are less common. Pigment stones are made up of calcium and bilirubin, the yellowish metabolic product of the red blood pigment.

Gallstones usually develop in the gallbladder. But they can also occur right in the bile ducts. Most bile duct stones form in the gallbladder and initially migrate into the common bile duct (Ductus choledochus). Another difference is the location: stones in the gallbladder are called cholecystolithiasis, while stones in the bile ducts are called choledocholithiasis.

Factors favoring gallstones include:

• Older age: the risk for gallstones increases from the age of 40 years.
• Genetic predisposition: this is present if gallstones have already occurred in multiple relatives.
• Sex: women are more likely to get gallstones.
• Pregnancy
• Contraceptive pill or estrogen tablets during menopause (hormone therapy).
• Malfunction of the gallbladder: the organ cannot contract properly and thus encourages the formation of stones.
• Short bowel syndrome: a secondary disease that can occur after a large portion of the small intestine has been surgically removed.
• Diabetes mellitus
• Certain antidiabetics (GLP-1 analogues)
• Cirrhosis of the liver: a severe liver disease that is caused by metabolic disorders or high Alcohol consumption.
• Severe overweight (obesity)
• Severe weight loss in a short time: for instance, in severely obese people whose stomachs have been surgically reduced in size.
• Specific, high-calorie oral liquid supplements and tube feeding
• A disease that causes increased decomposition of red blood cells (hemolysis)

Approximately 5 to 25% of the population have gallstones. People over 40 years of age are more frequently affected, women more than men. For most people, gallstones do not cause any symptoms.

The risk of complications is increased if typical symptoms occur. For example, there may be an inflammation of the gallbladder or pancreas, or in rare cases intestinal obstruction. Complications occur each year in about 0.2 percent of asymptomatic people with gallstones, compared to about 2 percent of people with gallstone symptoms.

In people with gallstones and without symptoms, the stones are sometimes discovered by accident – for instance during an ultrasound examination of the abdomen that was carried out for other reasons.

If typical symptoms occur, a targeted examination is performed. For a better indication of the symptoms, it is important to accurately describe all the symptoms to the doctor before the start of the examination.

The diagnosis is usually not very complex. After the initial interview, a physical examination and ultrasound of the abdomen follow. This is sufficient in most cases. To rule out other diseases being the cause of the symptoms, further examinations may be necessary.

Less frequently, a procedure known as endoscopic retrograde cholangiography (ERCP) is performed for diagnosis – usually only if the doctor is very sure that there are stones in the bile duct. In the course of this, the doctor performing the examination likewise pushes an endoscope through the esophagus, the stomach and the start of the duodenum to the opening of the bile duct. A contrast agent is then injected into the duct to make stones visible on the X-ray. During the examination, the stones can then not only be detected, but can also be removed directly using the endoscope.

Alternatively, magnetic resonance cholangiography (MRC) is a possible option. The patient lies in a magnetic resonance imaging scanner that creates sectional images of the biliary system “from the outside”. If gallstones are discovered that should be removed, this requires a separate procedure.

If gallstones are not causing any problems, they do not normally have to be treated. Many people with gallstones do not experience symptoms even over a longer period. Moreover, every treatment can have side effects, and operations always involve a degree of risk.

To relieve painful cases of colic, there are various analgesics and anticonvulsant drugs that alleviate the pain. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are especially effective. These analgesics help better than anticonvulsant agents. Symptoms like bloating or nausea can also be treated with drugs. Drugs are only rarely prescribed to eliminate gallstones. This is because they have a very limited effect and only work with small cholesterol stones.

If you want to permanently prevent painful colic and complications, removing your gallbladder or stones from the bile duct is the only option. Whether and when this step is expedient depends, among other things, on the severity of the symptoms, the risk of complications, and possible accompanying illnesses.

For people with very large gallstones or a certain form of porcelain gallbladder, there is an increased risk of developing gallbladder cancer. A porcelain gallbladder is a very rare disease whereby the wall of the gallbladder calcifies. In such cases, removal of the gallbladder may also be considered even if there are no symptoms.

You can find more detailed information about the treatment of gallstones, for example what the advantages and disadvantages of an operation are and how to manage without a gallbladder, at gesundheitsinformation.de.