The gallbladder is a small, pear-shaped organ below the liver. It stores bile, a greenish-yellow digestive juice the liver produces until the digestive system needs it. Bile consists of bile salts, electrolytes, bilirubin, cholesterol, and other fats (lipids).
GALL STONES and Dangerous Consequence: General | Gallstones | Rare diseases of the gallbladder | Gallstones in the gallbladder | Acute cholecystitis | Chronic cholecystitis | Bile duct tumors | Questions and Answers | Sources/references
Bile increases the solubility of cholesterol, fats, and vitamins in fatty foods so the body can better absorb them. Bile salts stimulate the colon to excrete water and other salts, which helps move intestinal contents through the colon and out of the body.
Bilirubin, a waste product consisting of the remains of spent red blood cells, is excreted in the bile. Breakdown products of drugs and waste substances processed by the liver are also excreted in the bile.
Image: Gallstones are clusters of crystals in the gallbladder or bile ducts.
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Bile flows from thin collecting ducts inside the liver into the left and right hepatic bile ducts, then into the common hepatic bile duct, and from there into the larger common bile duct. About half of the bile secreted between meals flows directly through the common bile duct into the small intestine.
The other half from the common bile duct detours through the gallbladder's bile duct and into the gallbladder, where bile is stored. Up to 90 percent of the water from the bile is absorbed into the blood. Only a concentrated solution of bile salts, bile fats, and sodium remains in the gallbladder.
When food enters the small intestine, hormonal and nerve signals trigger the gallbladder to contract, simultaneously opening the sphincter (Sphincter of Oddi). Bile flows from the gallbladder into the small intestine, mixes with the food being digested, and performs its digestive functions.
A large part of the gallbladder's stock of bile salts is released into the small intestine, and about 90 percent of the bile salts are reabsorbed into the blood through the wall of the lower part of the small intestine. The liver then excretes bile salts from the blood and back into the bile.
Bile salts thus circulate in the body 10 to 12 times a day. Each time, a small amount reaches the large intestine, where bacteria break them down. Some bile salts are reabsorbed in the colon; the rest are excreted with the feces.
Gallstones
Gallstones are clusters of crystals in the gallbladder or bile ducts (biliary tract). When gallstones are in the gallbladder, the condition is called hotel-thesis; when they are in the bile ducts, it is hotedohotithiasis. Gallstones are more common in women than in men. Risk factors for forming gallstones include age, obesity, Western-style diet, and hereditary predisposition.
Video content: How do we dissolve gallstones naturally?
The main component of most gallstones is cholesterol, but some are composed of calcium salts. Bile contains a lot of cholesterol, which usually remains liquid. If the bile becomes oversaturated with cholesterol, however, the cholesterol can become insoluble and precipitate out of the bile. Most gallstones form in the gallbladder, but most gallstones in the bile ducts get there from the gallbladder. Stones can form in the bile duct when bile stagnates because a duct is abnormally narrowed, or they can occur after gallbladder removal.
Gallstones in the bile ducts can cause severe or life-threatening infection of the bile ducts (cholangitis), pancreas (pancreatitis), or liver. When the bile duct system is blocked, bacteria can multiply and quickly anchor the infection in the ducts. Bacteria can spread into the blood and cause infections elsewhere in the body.
Symptoms
Gallstones usually do not cause symptoms for a long time, if they ever do, especially if they remain in the gallbladder. Rarely, however, large gallstones gradually erode the gallbladder wall and reach the small or large intestine, where they can cause intestinal obstruction; this is called gallstone ileus. Much more often, gallstones pass from the gallbladder into the bile ducts. They can travel through the small intestine without causing problems or stay in the ducts without causing bile flow obstruction or any symptoms.
When gallstones partially fall and temporarily block the bile duct, the patient experiences pain. Pain likes to come in fits; we call it colic. Typically, this pain rises slowly to a plateau and then gradually decreases. The pain can be sharp and occur at intervals, lasting for several hours. The location of the pain varies. It often hurts in the right upper abdomen, which can also be sensitive.
Image: If an infection develops with a blockage, the patient has fever, chills, and jaundice.
The pain may spread to the right shoulder blade. Often, the patient has nausea and vomiting; if an infection develops, the patient has fever, chills, and jaundice. Usually, the blockage is temporary and does not develop into an infection. Pain caused by water retention is sometimes indistinguishable from pain caused by gallbladder retention. A persistent blockage that blocks the gallbladder's bile duct causes gallbladder inflammation (acute cholecystitis).
Gallstones that block the pancreatic duct cause inflammation of the pancreas (pancreatitis), pain, jaundice, and even infection. Sometimes intermittent pain returns after gallbladder removal; such pain may be caused by gallstones in the common bile duct.
Symptoms of digestive problems and intolerance to fatty foods are often mistakenly attributed to gallstones. It is just as likely that a person with a spasm has a bloated stomach, a feeling of fullness and nausea, ulcer disease, indigestion, or gallstones. Pain in the upper right of the abdomen, which occurs after eating fatty food, may result from gallstones. Digestive problems after meals are common and rarely mean gallstones.
Diagnosis
The best method for identifying gallstones in the gallbladder is an ultrasound examination. Cholecystography is also effective. In cholecystography, X-ray images show the path of the congestive substance that the patient ingests and do not transmit X-rays when secreted into the bile and stored in the gallbladder.
If the gallbladder is not working, the contrast material will not appear. If the gallbladder is functioning, the contrast material will show the outline of the gallstone on the X-ray image. With a combination of ultrasound and cholecystography, the doctor can identify as many as 98 percent of gallstones in the gallbladder. However, these tests can give false positive results in rare people who do not have gallstones.
Rare diseases of the gallbladder
Cholesterol can be deposited in the gallbladder's lining. These layers look like tiny yellow spots on a red background (this is called a strawberry gall bladder). Sooner or later, non-cancerous growths (polyps) may form in the gallbladder. This disease can sometimes cause pain, so surgical removal of the gallbladder is necessary. Gallbladder diverticulosis, small, finger-like growths of the gallbladder lining, can develop with aging. Diverticulosis can cause inflammation, so surgical removal of the gallbladder is necessary.
Image: Diverticulosis can cause inflammation.
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When a person has abdominal pain, jaundice, chills, and fever, there is a high probability that they have gallstones in the bile ducts. Blood test results usually show a pattern of abnormal liver function, indicating a bile duct obstruction. More tests can provide additional information needed to make a firm diagnosis. These include ultrasound imaging, computed tomography, and various contrast-enhanced X-rays that show the bile ducts. B Ultrasound and CT imaging can show whether the bile duct is dilated. Still, the ducts can be blocked without being dilated.
X-ray methods help detect the blockage and, if present, show whether a gallstone causes it. The diagnostic X-ray method they use depends on the situation. If the diagnosis is pretty sure, many doctors use one of the X-ray methods before deciding on surgery. If the diagnosis is uncertain, ultrasound imaging may be the first step.
Treatment
Most people with "silent" gallstones in their gallbladder (those that do not cause symptoms) do not need treatment. People with occasional pain can try to avoid or reduce the consumption of fatty foods. This may prevent or reduce the number of pain attacks.
Gallstones in the gallbladder
If gallstones in the gallbladder cause repeated attacks of pain despite dietary changes, the doctor may recommend the removal of the gallbladder (cholecystectomy). Removal of the gallbladder does not cause nutritional deficiencies, and dietary restrictions are necessary after surgery. One to 5 people in every 1,000 who have this operation die. During the cholecystectomy, the doctor can also investigate the possibility of stones in the bile ducts.
Laparoscopic cholecystectomy was introduced in 1990 and turned surgical practice upside down in an incredibly short time. Now, most cholecystectomies are performed laparoscopically. In laparoscopic cholecystectomy, the gallbladder is removed through tubes introduced through small incisions in the abdominal wall.
The entire procedure is performed with the help of a camera (laparoscope), which is also placed in the abdomen through incisions. Laparoscopic cholecystectomy reduced postoperative complications, shortened the length of stay in the hospital, and reduced patient absences.
Video content: Understanding gallstones.
Other methods of gallstone removal introduced in the last 10 years include dissolution with methyl tertbutyl ether and sonication (lithotripsy). In the older method, gallstones were dissolved by long-term treatment with bile acids (heno- and ursodeoxycholic acid).
Gallstones in the bile ducts Gallstones in the bile ducts can cause serious problems; therefore, they must be removed either through abdominal surgery or a procedure called endoscopic retrograde cholangiopancreatography (ERCP). In ERCP, an endoscope is passed through the mouth, the esophagus, the stomach, and the small intestine. A contrast substance that does not transmit X-rays is injected into the bile duct through a tube in the sphincter of Oddi.
In a sphincterotomy procedure, the muscle sphincter is opened enough to allow the gallstones blocking the bile duct to pass through into the small intestine. ERCP and sphincterotomy are successful in 90 percent of patients.
Less than four people out of 1,000 die, and 3 to 7 percent of patients develop complications, so these procedures are safer than abdominal surgery. Immediate complications include bleeding, inflammation of the pancreas (pancreatitis), and perforation or infection of the bile ducts. In 2 to 6 percent of people, the ducts shrink again, and gallstones reappear. ERCP cannot remove gallstones that lie only in the gallbladder.
Picture: Gallstone removal methods also include lithotripsy.
Usually, ERCP alone is best for older people who have gallstones in the ducts and who have had their gallbladder removed before. In these people, the success of the intervention is comparable to the success of abdominal surgery. Most older people who have never had gallbladder problems do not need to have their gallbladder removed because only about 5 percent of older people get symptoms of gallstones in the bile ducts again.
People under the age of 60 who have problems with stones in the bile duct or gallbladder usually have their gallbladder removed electively after having previously had an ERCP and sphincterotomy. Otherwise, they risk developing acute problems with the gallbladder sometime later in the years. Most stones are removed from the bile ducts during the ERCP procedure. If gallstones remain in the duct, they will often travel through a permanent sphincterotomy later. Any remaining gallstones can then be removed by endoscopy before removing the drain in the bile duct that was inserted during the operation.
Acute cholecystitis
Acute cholecystitis is inflammation of the gallbladder wall, usually caused by a gallstone in the gallbladder's bile duct. Gallstones cause an attack of sudden, extremely severe pain. At least 95 percent of people with acute cholecystitis have gallstones. A bacterial infection can rarely cause inflammation.
Acute inflammation of the gallbladder without gallstones is a severe disease. It often occurs after injuries, operations, burns, infections spread throughout the body (sepsis), and very severe diseases, especially in patients who have been fed intravenously for a long time. A patient who usually had no prior symptoms of gallbladder disease suddenly experiences sudden, extremely severe pain in the upper abdomen. Usually, the disease is very severe and can lead to gangrene or perforation of the gallbladder. The diseased gallbladder must be removed by immediate surgery.
Symptoms
The first sign of gallbladder inflammation is pain, usually in the upper right part of the abdomen. The pain may become worse if the patient breathes deeply and often spreads to the lower part of the right shoulder blade. It can become very severe, and nausea and vomiting usually occur.
When the doctor presses on the upper right of the abdomen, the patient typically feels a sharp pain. The abdominal muscles on the right side become rigid for a few hours. Initially, the patient may only have a slightly elevated body temperature, which tends to rise more strongly over time.
Video content: Treatment of acute cholecystitis.
A gallbladder attack usually subsides within 2 or 3 days and disappears completely within a week. If this does not happen, the patient may have serious complications. High fever, chills, a significant increase in the concentration of white blood cells, and an interruption in the normal contraction of the intestine (peristalsis), called ileus, can mean the formation of an abscess, gangrene, or perforation of the gallbladder. These complications require immediate surgery.
There may be other complications. A gallbladder attack accompanied by jaundice or stagnation of bile in the liver indicates that the common bile duct may be partially blocked by a stone or inflammation. Suppose blood tests show an increased activity of the amylase enzyme. In that case, the patient may have pancreas inflammation (pancreatitis) caused by blockage of the pancreatic duct due to gallstones.
Diagnosis
Doctors diagnose acute inflammation of the gallbladder based on the patient's symptoms and the results of specific tests. Ultrasound imaging can often help confirm the presence of gallstones in the gallbladder and show thickening of the gallbladder wall. The most accurate diagnosis is given by hepatobiliary scintigraphy (imaging after intravenous injection of a radioactive substance). During this examination, the liver, bile ducts, gallbladder, and the upper part of the small intestine are imaged.
Treatment
A patient with acute gallbladder inflammation is usually admitted to the hospital, receives intravenous fluids, and is not allowed to eat or drink. The doctor can introduce a tube through the nose into the stomach so that the stomach is kept empty by suction, reducing gallbladder irritation. Antibiotics are usually administered immediately after acute gallbladder inflammation is suspected.
If the diagnosis is reliable and the risk of surgery is small, the gallbladder is usually removed in the first day or two after the onset of the disease. However, if the patient has another disease that increases the risk of surgery, the operation is postponed until that disease is treated. If the attack subsides, the gallbladder can be removed later, preferably in 6 weeks. If they suspect complications, e.g., abscess formation, gangrene, or perforation of the gallbladder, they generally require immediate surgery.
Image: Symptoms of sphincter of Oddi dysfunction can be mild or severe.
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A small percentage of people have new or recurring pain attacks that they describe as gallbladder attacks, even though they do not have a gallbladder. The cause of these attacks is unknown, but they could be due to abnormal functioning of the sphincter of Oddi; its opening controls the release of bile into the small intestine. It is believed that the pain is caused by increased pressure in the water, caused by resistance to the flow of bile or pancreatic secretions.
Small gallstones left after surgery can cause pain in some people. Your doctor can use an endoscope (a viewing tube with surgical tips) to dilate the sphincter of Oddi. This procedure usually relieves symptoms in people with an identifiable sphincter abnormality but will not help those who only have pain.
Chronic cholecystitis
Chronic cholecystitis is a long-term inflammation of the gallbladder characterized by repeated attacks of severe, sharp abdominal pain. A chronically inflamed gallbladder has a thick wall and is shrunken and small. The wall consists mainly of fibrous binder. The lining inside the gallbladder may show ulcers and scarring, and the gallbladder contains debris or gallstones that often block the gallbladder's bile duct. This condition is probably the result of repeated breakdowns and successive recoveries from previous bouts of acute inflammation, often due to gallstones.
Bile duct tumors
Excluding gallstones, the most common cause of bile duct obstruction is cancer. Most cancers start in the head of the pancreas, where the common bile duct runs. Less commonly, cancer originates in the biliary system at the junction of the common bile duct and the pancreatic duct in the gallbladder or liver. Much less commonly, cancer that has spread (metastasized) from elsewhere in the body can block the bile ducts, or the bile ducts can compress lymph nodes that have been attacked by lymphoma. Non-cancerous (benign) tumors can also obstruct the bile ducts.
Symptoms and diagnosis
Symptoms of bile duct obstruction are jaundice, abdominal discomfort, loss of appetite, weight loss, and itching, usually without fever and chills. Symptoms gradually worsen. Cancer diagnosis as the cause of the blockage is made by ultrasound imaging, computed tomography, or direct cholangiography (X-ray contrast imaging). To confirm the diagnosis, the doctor performs a biopsy.
Treatment
Treatment of bile duct tumors depends on the cause and circumstances. Surgery is the most direct way to determine the type of tumor, whether it can be removed, and ensure that bile can flow around the obstruction. Most often, the cancer cannot be removed entirely, and this type of cancer also does not respond well to radiation therapy. Partial relief of symptoms may be possible with chemotherapy.
Video content: Gallstones (cholelithiasis).
Some people with bile duct obstruction due to cancer have pain, and bacterial infection causes pus to build up. If surgery is not possible, the doctor may insert a tube to bridge the narrowing through a flexible endoscope, thereby allowing bile and possible pus to drain around the cancerous tumor. This procedure not only relieves the accumulation of bile or pus but also helps to control pain and relieve itching.
Questions and answers
What causes gallstones?
Gallstones form when bile stored in the gallbladder hardens into a stone-like material. Too much cholesterol, bile salts, or bilirubin (bile pigment) can cause gallstones[1].
What are the possible complications of gallstones?
Complications may include:
- Jaundice
- infection of the bile ducts (acute cholangitis)
- inflammation of the gallbladder (acute cholecystitis)
- acute pancreatitis
- gall bladder cancer
- ileus gallstone[2]
How are gallstones treated?
Cholecystectomy is an operation to remove the gallbladder. This is the only treatment option for symptomatic gallstones. Laparoscopic cholecystectomy is the most common procedure instead of the traditional, open procedure[3].
Can children also get gallstones?
Gallstones are solid deposits of digestive fluid in the gallbladder, a small organ just below the liver. Although the disease is more common in adults, about 2 percent of children are diagnosed with gallstones[4].
Are gallstones painful?
The pain usually lasts from a few minutes to a few hours. Occasionally, people with gallstone pain may feel sick or even vomit. The pain often follows a meal and can most often be noticed in the evening[5].
Sources and references
Extensive health manual for home use, Youth Book Publishing House
- Gallstones - https://www.hopkinsmedicine.org
- Complications - https://www2.hse.ie
- Gallstone Disease Treatment - https://www.hopkinsmedicine.org
- Gallstones (Cholelithiasis) - https://www.childrenshospital.org
- Gallstones - https://gutscharity.org.uk
