In New Zealand approximately 10% of all adults will have gallstones. They occur in the gallbladder when chemicals that are usually dissolved in bile form crystals that cling together to form stones.
The stones may stay in the gallbladder and cause no symptoms, or they may irritate the gallbladder wall or block gallbladder ducts, resulting in infection, inflammation and upper abdominal pain. It is possible for the infection to spread to the liver or pancreas. Treatment can range from pain relief to surgery.
The gallbladder is part of the digestive system. It is a pear-shaped, sac-like structure approximately 8 cm long and 2.5 cm wide, located alongside the stomach and attached to the lower surface of the liver. The function of the gallbladder is to concentrate, store and excrete bile, a fluid that helps in the digestion of fat.
Bile is yellow-green in colour and has several components including cholesterol, bile salts and bile pigments (eg. bilirubin). It is these chemicals that can crystalise and form stones. The presence of gallstones in the gallbladder is known as cholelithiasis. Infection and inflammation of the gallbladder is known as cholecystitis.
What causes gallstones?
The risk of developing gallstones tends to increase with age. Heredity appears to play a part in the development of gallstones and there is frequently a family history of the disease. Women develop gallstones more commonly than men and at a younger age.
Other factors that increase the risk of developing gallstones include:
- Being overweight – particularly when the extra weight is carried around the waist
- Eating a high fat, low fibre diet
- Being diabetic
- Having high cholesterol
- Heavy drinking
As pregnancy and contraceptive pills can slow down gallbladder activity, women who have had multiple pregnancies or long-term contraceptive pill use are at higher risk of developing gallstones.
Signs and symptoms
Gallstones vary in chemical structure. The two main types of gallstones are:
The amount of cholesterol that can dissolve in bile depends on how much bile salt it contains. Too much cholesterol, or too little bile salt, tends to cause gallstones to form in the gallbladder. Approximately 80% of all gallstones are cholesterol stones.
These are formed by calcium and bilirubin and account for approximately 20% of all gallstones. Pigment stones tend to form in patients with haemolytic anaemias (fragile red blood cells), including sickle-cell disease and thalassaemia.
Gallstones vary greatly in size. Some people may form one large stone, whereas others may have hundreds of tiny stones. Most commonly, gallstones are 5-10 mm in diameter.
Most people with gallstones do not experience any symptoms. If symptoms are present, the most common early sign of gallstones is upper abdominal pain. This pain usually occurs in the upper right side of the abdomen, is often severe, and may radiate to the chest, back or the area between the shoulders. Other symptoms that may occur include:
- Nausea or vomiting
- Jaundice (the yellow appearance of skin and the whites of eyes caused by bilirubin build-up in the blood) when gallstones block the passage of bile
- Light coloured stools.
Symptoms can occur suddenly and may be referred to as biliary colic. This type of pain is commonly set off by eating fatty foods and often occurs in the middle of the night. The symptoms experienced may be so severe that people need to seek immediate medical attention.
When infection of the gallbladder is present it is possible to also experience low-grade fever, sweats and chills.
If gallstones are suspected, it is important to consult a doctor for an accurate diagnosis and treatment. Initially the doctor will take a medical history and perform a physical examination. The doctor will look for signs of jaundice and will assess the abdomen for swelling and pain. Blood tests are usually performed to check the function of the liver and pancreas and to rule out other conditions that may be causing the symptoms.
The most common test used to definitively diagnose gallstones is an ultrasound scan.
If it is suspected that gallstones are blocking the ducts then a test called endoscopic retrograde cholangiopancreatography (ERCP) may be performed. This test involves inserting a long, flexible tube (an endoscope) down the oesophagus, through the stomach and into the duodenum. The endoscope has a light and a camera at its tip allowing the doctor to view the inside of the bowel. A special dye is injected through the endoscope into the bile duct allowing the outline of the ducts to be highlighted. Gallstones located in the ducts can sometimes be removed during the ERCP procedure.
Other specialised scans or x-rays (eg: fluoroscopy, radioisotopic scan) are sometimes used to confirm the diagnosis and highlight the location of the gallstones.
In general, treatment will depend on the frequency and severity of the symptoms experienced. Approximately 30% of all people who experience biliary colic will not experience a further episode. Because of this, the doctor may advise a wait and see approach.
If attacks are occasional and mild, they may be able to be managed with pain-relieving medications, applying heat to the affected area, resting and taking sips of water. Reducing the amount of fat in the diet and maintaining a healthy body weight may also be beneficial. If attacks are frequent or severe surgery is usually recommended.
Cholecystectomy is the surgical removal of the gallbladder. It is a common and routine procedure and may be recommended when the symptoms of gallstones are problematic and/or cholecystitis is present. The two commonly used cholecystectomy techniques are:
This is the "traditional" surgical technique for removing the gallbladder and is performed under a general anaesthetic. A single incision is made below the rib cage. Through the incision the surgeon can view the area and remove the gallbladder. The cystic duct is tied off or closed with surgical clips. The common bile duct is left intact. The incision in the skin is closed with dissolvable stitches or staples.
Laparoscopic cholecystectomy is less invasive than an open cholecystectomy and is the most commonly used surgical technique for removing the gallbladder. It has a faster recovery time and a shorter hospital stay. In a laparoscopic cholecystectomy three or four small incisions are made in the abdomen. A telescope-like instrument (a laparoscope) is inserted through one incision and surgical instruments are inserted through the other incisions. The laparoscope has a camera and a light on its tip allowing the surgeon to view the inside of the abdominal cavity on a television monitor. The abdominal cavity is inflated with carbon dioxide gas to provide a clear field of vision and to give the surgeon room to operate. The gallbladder is located and the cystic duct is tied off or closed with surgical clips. The gallbladder is then removed through an incision in the belly button. The operation is performed under general anaesthetic and the patient can usually be discharged after a one-night stay in hospital.
When the gallbladder is removed, bile is still produced by the liver and excreted through the bile duct. Instead of being stored by the gallbladder until needed, it flows directly into the duodenum and is excreted from the body. If there is infection or acute inflammation of the gallbladder, this may need to be treated with antibiotics before the gallbladder can be removed.
Recovery time will largely depend on the surgical technique used. The surgeon will recommend recovery and activity guidelines before the patient’s discharge from hospital.
After a cholecystectomy fluids may be given intravenously (through a drip in the hand or arm). Oral fluids and a light diet are introduced slowly and people are encouraged to get up and walk around soon after the operation. Once discharged, light activities only will be recommended. Heavy lifting or vigorous exercise should be avoided. Those who have had a laparoscopic cholecystectomy can usually return to their normal daily routines within one to two weeks after surgery. Those who have had an open cholecystectomy may take between two and four weeks to return to their normal daily routines. The recovery period differs according to each individual.
After discharge from the hospital the digestive system may take a few days to return to normal so low fat, easily digestible food is recommended. A normal diet can be resumed after this but if certain foods cause discomfort they should be avoided. The surgeon may organise a follow up appointment some time after discharge to assess recovery.
Risks and complications
As with any surgery, there are possible risks and complications. These include:
- Anaesthetic complications
- Bleeding (haemorrhage)
- Wound infection
- Injury to or leakage from the bile duct
- Discomfort or numbness around the area of incision
It is important to discuss the risks and benefits of cholecystectomy with the surgeon before surgery. These factors vary with each individual case.
After surgery, inform the doctor immediately if any of the following are experienced:
- Fever or chills
- Drainage from the incision site(s)
- Increasing pain or redness around the incision
Anderson, K.N., Anderson, L.E. & Glanze, W.D. (eds.) (2006) Mosby’s Medical, Nursing, & Allied Health Dictionary (6th ed.) St. Louis: Mosby-Year Book, Inc.
British Digestive Foundation (Date unknown) Understanding gallstones London: British Digestive Foundation
Haggerty, M. (2006) Gallstones. The Gale Encyclopaedia of Medicine. Third Edition. Jacqueline L. Longe. Editor. Farmington Hills. MI. Thompson Gale.
Polsdorfer, J. R. (2006) Gallstone Removal. The Gale Encyclopaedia of Medicine. Third Edition. Jacqueline L. Longe. Editor. Farmington Hills. MI. Thompson Gale.
Last Reviewed – 22 February 2013