Gallstones

The gallbladder often seems more trouble than it's worth. This small storage pouch plays a minor role in the body, but it's a major source of disease. Specifically, the organ can become a breeding ground for gallstones, hard crystals that can cause absolute misery.

Each year, about 1 million Americans develop gallstones. More than half never experience any troubling symptoms, and their gallstones generally don't have to be removed. That still leaves hundreds of thousands of people in need of help, however. Fortunately, gallstones are usually no match for modern medicine. If you're troubled by them, talk to your doctor about your options. Before long, those stones should be history.

What causes gallstones?

The gallbladder is a storage container for bile, a caustic liquid that helps break down fat in the diet. Bile is a stew of many dissolved compounds, including cholesterol and bilirubin (a waste product that makes stools brown). Like the sugar in a jar of honey, both cholesterol and bilirubin can drop out of solution and crystallize -- essentially become "undissolved." Before visible stones develop, microscopic crystals may clump together to form a thick gel known as biliary sludge.

Cholesterol is the main ingredient in roughly 80 percent of all gallstones. These are called cholesterol stones. The rest, called pigment stones, are made chiefly of bilirubin. Whatever the building material, stones can be as small as a grain of sand or as large as a golf ball. Some people have a single stone; others have hundreds or even thousands (in which case, the gallbladder, if opened up, can look something like a geode).

Gallstones have several different causes, some better understood than others. An overload of cholesterol or bilirubin in the bile can definitely contribute to stone formation. In addition, certain proteins seem to act like seeds to help stones form. You may also develop stones if your gallbladder doesn't contract properly to empty itself, leaving more time for bile to just sit around.

What are the symptoms of gallstones?

Blockages caused by the stones induce a sudden wave of pain in the upper abdomen. The attack quickly grows in intensity, then fades anywhere from 30 minutes to several hours later. You may also experience pain under the right shoulder, pain between the shoulder blades, nausea or vomiting. Signs of a potential emergency situation include sweating, chills, low-grade fever, and clay-colored stools.

Who is at risk?

For unknown reasons, women are prime targets for gallstones. Among adults under 60, women are three times as likely as men to have gallstones. For both men and women, the risk rises after age 60. Stones are also relatively common in Native Americans, people with diabetes, obese people (especially obese women), women who take hormones, anyone who takes cholesterol-lowering drugs, and anyone who rapidly loses weight. Researchers are also looking into the genetic tendency to develop gallstones, and eight to 10 genes associated with cholesterol gallstones have already been identified.

What are the complications of gallstones?

Stones that stay in the gallbladder are generally harmless. The real trouble begins when a stone gets lodged in one of several tubes or "ducts" that carry bile. Blockages can occur in the hepatic duct (which carries bile out of the liver), the cystic duct (which transports bile to and from the gallbladder) or the common duct (which collects bile from the other ducts and delivers it to the intestines).

When the natural flow of bile breaks down, the blocked duct and the gallbladder can become inflamed. Less often, the liver or pancreas becomes inflamed as well. If not treated, the blockage could lead to a serious infection of the duct. The inflamed organ can also become permanently damaged. In rare cases, the damage could be fatal.

How are gallstones treated?

Like your wisdom teeth, the gallbladder is entirely disposable. To get rid of gallstones, among other reasons, American surgeons remove about 700,000 gallbladders every year -- an operation doctors call a cholecystectomy.

In addition to being very effective, the modern operation is generally safe and recovery is relatively quick and easy. Almost all modern cholecystectomies are performed with a special instrument called a laparoscope. Instead of slicing open the belly, the surgeon inserts thin surgical instruments and tiny video cameras through very small incisions in the abdomen. Most patients leave the hospital the same day and return to work within a few days.

For patients who can't have surgery or have a strong preference not to, there are other options. One is Actigall, a drug that slowly dissolves the stones. Unfortunately, the drug takes months or even years to work, and there's a 50/50 chance the stones will eventually come back. Another option is lithotripsy, a procedure that uses shock waves to break apart the stones. In theory, the resulting fragments may be small enough to escape through the bile duct. In practice, however, lithotripsy tends to turn large, troublesome stones into small, troublesome stones.

If you have a stone stuck in one of your ducts, the stone may need to be removed in a separate procedure. The removal can be performed either laparoscopically or with an endoscope. The relief you feel will make it all worthwhile.

References

What's new with gallstones? MedicineNet, undated. http://www.medicinenet.com/gallstones/page20.htm

Ahmed, A. et al. Management of gallstones and their complications. American Family Physician.

American Gastroenterological Association. Understanding Gallstones.

Food and Drug Administration. Medical Device Approvals and Clearances.

National Digestive Diseases Information Clearinghouse. Gallstones.

American College of Gastroenterology. Gallstones.

University of Maryland Medical Center. Gallstones and Gallbladder Disease. June 2009.

Pedro RN, Lee C, Weiland D, et al. Eighteen-year experience with the Medstone STS lithotripter: safety, efficacy, and evolving practice patterns. Journal of Endourology 22(7): 1417-21.

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