An in-depth guide to gallstones

Gallstones are a very common condition that is more common in women than men. They are often asymptomatic, but can cause extreme pain in about 20% of cases. In his latest article, renowned consultant general and hepato-pancreato-biliary Mr Deepak Hariharan explains this condition in detail, including the causes and available treatments.

What are gallstones?

Gallstones are the precipitation of firm to hard natural material (cholesterol and bile pigments) within the gallbladder. This is a natural process of wear and tear, and affects women more than men. There is no genetic or familial predisposition.

The gallbladder itself is a pear-shaped organ lying underneath the liver, the largest organ in the body, under the right rib cage. The gallbladder drains bile via a small orifice into a tube (cystic duct) attached to the main bile tubes (right and left hepatic ducts) which drain bile made in the liver to form a common channel (common bile duct), which joins the stomach and small bowel (duodenum), where digestion takes place.

The main function of the gallbladder is to concentrate bile by absorbing water. It releases saturated bile on demand, as bile helps break down and digest fats in our food eaten to release energy, enabling us to carry out and sustain day-to-day activities.

What are the signs and symptoms of gallstones?

The symptoms of gallstones vary depending on the position, size, number and location of the gallstone. Commonly, symptoms occur in 20 % of the population whilst a large proportion remains asymptomatic.

Appreciating symptoms is key as symptomatic gallstones warrant treatment considerations, whereas asymptomatic, incidentally discovered gallstones require no treatment.

Symptoms often occur as gallstones may impede or block the flow of bile from the gallbladder into the bile duct. Stones can also move outside the gallbladder into the bile duct to obstruct the flow of bile into the duodenum, or irritate the pancreas.

Large stones over time can cause the death of tissues, or the stones could erode through the gallbladder into the liver, bile tube or stomach. The impedance of flow of concentrated bile from the gallbladder may cause the pear-shaped organ to swell leading to on-and-off pain/discomfort underneath the right rib cage, central upper abdomen made worse on eating fatty food, nausea, and vomiting. This symptom complex is defined as biliary colic.

If the stone interrupts the flow of bile from the gallbladder, the stagnant supersaturated bile has the potential of getting infected. This leads to fever, sweating and excruciating pain in the centre upper abdomen and often on examination there is tenderness elicited by feeling underneath the right rib cage at the height of deep breath taken.

These are suggestive of infection in the gallbladder or acute cholecystitis. Rarely the infection persists and if untreated or delayed the patient presents with severe illness, generalised abdominal pain and sepsis raising concerns for rupture of a gallbladder, which causes the accumulation of bile in the abdomen causing peritonitis or liver abscess.

In the event the stone slips and lodges in the common bile duct it can cause jaundice. This is a symptom where the patient turns yellow.

A sign that if it irritates the pancreas then the patient presents with severe, acute, sudden onset upper abdominal pain radiating to the back. This causes profuse nausea, vomiting and inability to eat leading to acute pancreatitis. In some cases, this can be a life-threatening complication of gallstone disease.

What causes gallstones?

Cholesterol stones remain the most common type of gallstone. The predominant component of bile is cholesterol, an emulsifier that aids in the absorption of fat from foods, alongside bilirubin; a by-product of the breakdown of haem, a major component of aged red blood cells. The excess of haem breakdown contributes to the formation of pigment stones.

The concentration, super-saturation and absorption of water from the secreted bile made in the liver within the gallbladder lead to the formation of cholesterol or mixed (cholesterol and pigment) gallstones.

How are gallstones treated?

Gallstones are often diagnosed by ultrasound, a radiological examination tool following clinical assessment by medical personnel. Treatment for gallstones is recommended only if the patient is symptomatic. The gold standard treatment for symptomatic gallstones is surgery in the form of laparoscopic cholecystectomy performed under general anaesthetic subject to clinical and anaesthetic assessment before proceeding with surgery.

Incidentally discovered gallstones on imaging where patients have no symptoms warrant no treatment. Patients ought to be aware of the symptoms that may develop in future and be prepared to seek surgical help/consultation if any of these were to occur.

What are the ways to manage the risks of getting gallstones?

Awareness is essential, especially amongst women who are obese and those who are over the age of forty. In women, the female hormone oestrogen plays a vital role in regulating/increasing cholesterol levels in the body. Excess weight loss or gain contributes to increases in cholesterol levels in the body, which may predispose to forming gallstones.

Those at risk ought to regulate their intake of foods rich in fats (butter, cakes, red meat, cheese), eat a well-balanced diet, healthy weight with normal body mass index and consulting your general physician with regards to certain medications may contribute to reducing the risk of developing gallstones or symptoms from it.

Mr Deepak Hariharan is a leading consultant general and hepato-pancreato-biliary surgeon based in London. If you would like to book a consultation with Mr Hariharan you can do so right now via his Top Doctors profile.