Cholelithiasis

1 What is cholelithiasis?

Cholelithiasis definition

Cholelithiasis is a medical term for gallstones, which are stones formed from the bile. Gallstones are somewhat common, especially in middle-aged men and women. In fact, many people who have gallstones have no idea that they have it. Many cases of gallstones do not cause any symptoms at all, especially if the stones are few and small. Another fact you should know is some cases of gallstones do not need to be treated.

We will discuss the normal functioning first before proceeding to the problem. The sole function of your gallbladder is to store the bile constantly secreted by the liver. The gallbladder acts like a pouch that expands as it collects bile from the liver, and shrinks to release the bile into the digestive tract. The body uses bile to digest fats in food. However, bile is not needed between meals, so the gallbladder stores it and releases it when needed. Bile is made up of cholesterol, bilirubin, and inorganic salts.

Cholelithiasis can be treated with surgery that removes the stones, sometimes including the gallbladder. There are also medicines that dissolve tiny gallstones. Doctors recommend removal of gallstones if it blocks the flow of bile, may cause rupture to soft tissues, or if there are repeated symptoms. Some people experience recurring gallstones.

There are different types of gallstones, depending on its makeup. White-yellowish stones are made largely from cholesterol, while dark shiny stones are made up of bile pigments. Some patients have brownish ‘mixed stones’ composed of cholesterol, bile salts, and minerals such as calcium. The amount of calcium in gallstones is medically important, as higher amounts make it more visible to x-rays that aids in diagnosis.

The shape of gallstones can range from small ‘rocks’ to stones with faceted sides. Some have somewhat large cylindrical shape. Gallstones take many years to form and grow. Although some have few or small gallstones that do not cause any trouble, it may do so over time.

There are several factors causing gallstones to form. Sometimes, the makeup of the bile coming out of the liver is somewhat different, containing higher quantities of cholesterol and lower bile salts that are more conducive to the formation of stones. Another factor is the functioning of the gallbladder. Having infrequent or fewer meals may cause the gallbladder to contract infrequently and store bile longer, which is also a risk factor for stone formation. Things that cause the bile salts to form crystals or problems that impede the normal flow of bile are also risk factors.

2 Cholelithiasis symptoms

Gallstones may not cause symptoms or problems at all. Cholelithiasis can cause trouble by blocking the flow of bile, either by clogging the gallbladder or traveling through the cystic duct (the tube that connects the gallbladder to the intestine) to cause blockage. Some gallstones are also large and sharp that cause the gallbladder to become inflamed (called cholecystitis). If not treated, cholecystitis can result to death of the gallbladder tissues (gangrene) or rupture.

Symptomatic cholelithiasis

Symptomatic cholelithiasis is a term for gallstones that cause symptoms. Note that many gallstone cases do not cause symptoms.

Here are the signs and symptoms of a gallstone that has caused a blockage in the flow of bile:

  • Sudden pain that intensifies rapidly in the upper right abdomen or just below the breastbone
  • Back pain between the shoulder blades
  • Pain in the right shoulder
  • Nausea and vomiting
  • Pain is usually dull, sharp, or cramping
  • Pain usually lasts several minutes to hours

Some people experience blockage of flow of bile for a long time. The gallstone may have migrated to the pancreas or the small intestine.

Here are those signs and symptoms:

  • High fever, with a temperature of 100 degrees Fahrenheit or higher
  • Persistent pain
  • Rapid heartbeat
  • Yellowing of the skin and eyes
  • Itchy skin
  • Diarrhea
  • Chills
  • Confusion
  • Loss of appetite

Some severe cases of gallstones cause the gallbladder to burst, which requires removal. Gallbladder rupture may have similar symptoms to blockage of flow of bile.

Here are symptoms of possible gallbladder rupture:

  • Pain in the abdomen that is so bad, you can’t stand, sit, or be in a comfortable position
  • Pain after meals
  • Nausea
  • Yellowing of the skin or eyes (jaundice)
  • High fever (100F and above) with chills

Some symptoms of gallstones, like jaundice and severe pain, require emergency treatment. Early symptoms of gallstones causing problems to bile flow should require immediate medical attention. If left untreated, the gallstone can completely block the biliary duct and cause the gallbladder to swell and rupture.

3 Risk factors for cholelithiasis

Bile can form stones when it becomes stagnant. Measures such as a constant flow of bile from the liver and frequent emptying of the gallbladder during meals prevent bile salts from concentrating and forming stones. That explains why problems in the flow of bile cause gallstones. Problems in the gallbladder such as inflammation, polyps, or growths can also disturb bile flow.

There are plenty of factors, including genetics and environment, that cause gallstones to form. In fact, most people have one or more risk factors.

Risk factors include the following:

  • American Indian, Hispanic, and Chilean ethnicities
  • Gallstones are more common in women than in men. However, cases of gallstones in men are often much worse
  • Having multiple pregnancies
  • Obesity. Higher fat in the abdomen may constrict flow of bile
  • Family history of gallbladder disease
  • Taking estrogen hormones or pills, which can increase cholesterol in the bile
  • Diet high in carbs and fats
  • Low fiber intake
  • Rapid weight loss
  • Having disease in the liver
  • Having type 2 diabetes
  • High cholesterol or trigylcerides
  • Sedentary lifestyle.
  • Taking drugs for losing weight, like Orlistat (Xenical)
  • Taking oral contraceptive pills

4 Diagnosing cholelithiasis

Your doctor will first assess your symptoms and perform a physical examination. He or she will also gather medical history when diagnosing cholelithiasis. You might be asked about things like family history of gallstones or having a disease in the gallbladder and liver, medicines taken (including birth control pills), previously diagnosed health problems, daily diet preferences, and history of losing weight.

The doctor will also order blood tests will check for infection. You will also undergo liver function tests, which check for liver enzymes and bilirubin in the blood. These tests may be ordered and done repeatedly.

X-rays in the abdomen may help visualize presence of gallstones. X-rays will also check for a condition called porcelain gallbladder, which occurs when deposits of calcium line the inside of the gallbladder. However, not all gallstones show up in x-rays.

Gallstones are better seen using ultrasonography (ultrasound, the similar device used on pregnant mothers). It does not cause radiation, and it is a choice because it is non-invasive, specific, and inexpensive. Ultrasonography can easily detect gallstones larger than 2 mm. However, it relies on the skill of the doctor.

The more sophisticated computed tomography scanning (CT scan) and magnetic resonance imaging (MRI) can also be used, but they are expensive. MRI is more sensitive than ultrasound and can detect tiny gallstones down the biliary duct.
Techniques involving a dye can be used to detect very tiny gallstones or obstructions in the biliary duct. The procedure endoscopic retrograde cholangiopancreatography (ERCP) involves infusing a dye to the outlet of bile into the duodenum (ampulla of Vater) using an endoscope. The dye shows up clearly on x-rays, which helps detect gallstones, tumors, or other obstructions in the biliary tree. Another technique called percutaneous transhepatic cholangiography (PTC) involves injecting a dye in the bile-carrying vessels in the liver, which detects obstructions from the liver to the gallbladder.

5 Treating cholithiasis

Treatment of gallstones depends on the numbers and size of the stones, as well as the health of the patient. For gallstones that do not cause any symptoms, doctors may recommend monitoring as further intervention may cause problems. Most patients with asymptomatic cholelithiasis develop symptoms in 10 years. Once symptoms develop, treatment is always necessary. Treatment along with removal of the gallbladder is also needed for large gallstones, those at risk for gallbladder cancer, and patients with spinal cord injuries and sickle-cell anemia, whose distinction between painful crisis and cholecystitis may be difficult to distinguish.

Some gallstones can be dissolved with a medication called ursodeoxycholic acid (Ursodiol). It works by reducing levels of cholesterol in the bile that prevents bile salt crystals from forming. It has to be taken for a long-term and it only works for very small cholesterol gallstones. However, 50% of patients form new gallstones within 5 years after discontinuing treatment.

The classic treatment for gallstones is removal of the gallbladder. It is done in an operation called cholecystectomy, and it is often indicated for those with symptoms or facing complications. If imaging studies found that there are gallstones in the common bile duct, it will be explored for stones during surgery to be removed. In many cases, cholecystectomy is done using laparoscopy, which use sophisticated metal devices that allow surgeons to operate using fewer smaller incisions rather than open surgery. Laparoscopy also allows faster recovery than open surgery. During the surgery, the gallstones are collected, counted, and examined in the laboratory. Removal of gall bladder is not a guarantee, as gallstones can still form in the remaining bile ducts.

Among the potential problems with surgery is losing gallstones into the peritoneal cavity and damage to the common bile duct. In case of lost gallstones, you may have to undergo several follow-up ultrasounds for 12 months. Injury to the common bile duct is a problem because it may cause problems with the flow of bile that induces new gallstones to form. Most of these problems are relatively uncommon.

Some patients have gallstones in the common bile duct that cannot be removed due to poor health or other health problems. In this case, the doctor may make a make an opening in the bile duct to create access to the stones for extraction. The procedure is performed using an endoscope, a long, thin tube inserted in the throat and threaded to the stomach and duodenum, eliminating the need for surgery. It is often done if there are stones left during a previous operation or prevent inflammation of the pancreas caused by gallstones in patients who are too sick to have surgery. It may also be done before removal of the gallbladder to reduce the need to explore the common bile duct for stones.

6 Prevention and monitoring

Gallstones can form again, so you need to do some preventive measures after treatment. Your doctor may prescribe Ursodeoxycholic acid to prevent new gallstones. You also have to do simple measures like losing weight slowly, reduce intake of fat in the diet, eat meals on a schedule to promote good flow of bile, and engage in regular exercise. These measures are helpful in reducing risk of forming new gallstones.

Your doctor will teach you to monitor for biliary colic, which is caused by temporary blockages of bile flow. Watch out for symptoms such as sharp pain in the upper right abdomen, nausea, and vomiting. The pain tends to radiate to the right shoulder or behind the breastbone. Many patients experience biliary colic even though there are no gallstones or blockage of bile. In that case, the doctor may order diagnostic tests to determine the true cause. You will also be monitored for acute pancreatitis, which is caused by gallstones causing irritation of the pancreas. Symptoms of possible acute pancreatitis include sudden severe pain in the abdomen, diarrhea, and malaise.

Chronic diarrhea is a common finding in patients whose gallbladders were removed. It happens because the bile continuously flows into the intestines. In the large intestine, bile salts stimulate secretion of water and salts, making the feces more fluid, resulting in diarrhea. Usually, the diarrhea is mild and can be managed by taking anti-diarrheal drugs. If diarrhea becomes more frequent, your doctor may prescribe medicines that bind to bile salts, such as Colestipol, Cholestyramine, and Colesevelam.

Many patients with gallstones and those whose gallbladders were removed recover and are able to live a normal life after surgery. Treatment might be more complicated if gallstones managed to enter the common biliary duct. The patient may need more diagnostic work, more procedures (like endoscopy), and surgery to remove the gallstones and fix the damaged biliary duct.

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