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 surgeries are among the most common operations. About 170,000 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. In addition, other symptoms are possible, such as burping, 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. This results in the typical yellow discolorations.

Bile fluid consists of water and various substances some of which are not water-soluble. If these substances agglutinate, gallstones can develop. That probably happens because the composition of the bile fluid comes from the balance, for example with too high an amount of cholesterol. As yet, it is unclear why exactly stones then form.

Gallstones are most commonly composed of cholesterol. More rarely, they develop from pigment stones. 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: gallstones are more common in women; the female sex hormone may be to blame.
• 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
• Cirrhosis of the liver: a severe liver disease that is caused by metabolic disorders or high alcohol consumption.
• Obesity
• Severe weight loss in a short time: for instance in severely obese people whose stomach was surgically shrunk.
• 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. They form more often in women and older people. 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. Every year, about 0.2% of people with gallstones experience complications.

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.

Alternatively, magnetic resonance cholangiography (MRC) and an endoscopic ultrasound examination (endosonography) are possible. MRC and endosonography are not associated with radiation exposure. With MRC, tomographic images of the biliary system are created, moreover no endoscopy is needed. Unlike with the endoscopic X-ray examination, it is not possible to remove the stones already during the examination. This requires a special operation.

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.

In order to prevent painful colic, removal of the gallbladder is the only option. Whether and when this step is expedient depends on the severity of the symptoms and risk of complications, among other things.

In patients with a 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. The usual recommendation here is to have the gallbladder removed as a precaution 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.