Gallstone

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Gallstone
SynonymsGallstone disease, cholelith, cholecystolithiasis (gallstones in the gallbladder), choledocholithiasis (gallstones in the common bile duct) [1]
Human gallstones 2015 G1.jpg
Numerous small gallstones made up largely of cholesterol
Pronunciation
Specialty General surgery
SymptomsNone, crampy pain in the right upper abdomen [2] [3] [4]
Complications Inflammation of the gallbladder, inflammation of the pancreas, liver inflammation [2] [4]
Usual onsetAfter 40 years old [2]
Risk factors Birth control pills, pregnancy, family history, obesity, diabetes, liver disease, rapid weight loss [2]
Diagnostic method Based on symptoms, confirmed by ultrasound [2] [4]
PreventionHealthy weight, diet high in fiber, diet low in simple carbohydrates [2]
TreatmentAsymptomatic: none [2]
Pain: surgery [2]
PrognosisGood after surgery [2]
Frequency10–15% of adults (developed world) [4]

A gallstone is a stone formed within the gallbladder out of bile components. [2] The term cholelithiasis may refer to the presence of gallstones or to the diseases caused by gallstones. [5] Most people with gallstones (about 80%) never have symptoms. [2] [3] When a gallstone blocks the bile duct, a cramp-like pain in the right upper part of the abdomen, known as biliary colic (gallbladder attack) can result. [4] This happens in 1–4% of those with gallstones each year. [4] Complications of gallstones may include inflammation of the gallbladder (cholecystitis), inflammation of the pancreas (pancreatitis), jaundice, and infection of a bile duct (cholangitis). [4] [6] Symptoms of these complications may include pain of more than five hours duration, fever, yellowish skin, vomiting, dark urine, and pale stools. [2]

Calculus (medicine) concretion of material, usually mineral salts, that forms in an organ or duct of the body

A calculus, often called a stone, is a concretion of material, usually mineral salts, that forms in an organ or duct of the body. Formation of calculi is known as lithiasis. Stones can cause a number of medical conditions.

Gallbladder organ in humans and other vertebrates

In vertebrates, the gallbladder is a small hollow organ where bile is stored and concentrated before it is released into the small intestine. In humans, the pear-shaped gallbladder lies beneath the liver, although the structure and position of the gallbladder can vary significantly among animal species. It receives and stores bile, produced by the liver, via the common hepatic duct and releases it via the common bile duct into the duodenum, where the bile helps in the digestion of fats.

Bile fluid produced by the liver of most vertebrates that aids the process of digestion.

Bile or gall is a dark green to yellowish brown fluid, produced by the liver of most vertebrates, that aids the digestion of lipids in the small intestine. In humans, bile is produced continuously by the liver, and stored and concentrated in the gallbladder. After eating, this stored bile is discharged into the duodenum. The composition of hepatic bile is 97% water, 0.7% bile salts, 0.2% bilirubin, 0.51% fats, and 200 meq/l inorganic salts.

Contents

Risk factors for gallstones include birth control pills, pregnancy, a family history of gallstones, obesity, diabetes, liver disease, or rapid weight loss. [2] The bile components that form gallstones include cholesterol, bile salts, and bilirubin. [2] Gallstones formed mainly from cholesterol are termed cholesterol stones, and those mainly from bilirubin are termed pigment stones. [2] [3] Gallstones may be suspected based on symptoms. [4] Diagnosis is then typically confirmed by ultrasound. [2] Complications may be detected on blood tests. [2]

Pregnancy time when children develop inside the mothers body before birth

Pregnancy, also known as gestation, is the time during which one or more offspring develops inside a woman. A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy can occur by sexual intercourse or assisted reproductive technology. Childbirth typically occurs around 40 weeks from the last menstrual period (LMP). This is just over nine months, where each month averages 31 days. When measured from fertilization it is about 38 weeks. An embryo is the developing offspring during the first eight weeks following fertilization, after which, the term fetus is used until birth. Symptoms of early pregnancy may include missed periods, tender breasts, nausea and vomiting, hunger, and frequent urination. Pregnancy may be confirmed with a pregnancy test.

Obesity medical condition in which excess body fat harms health

Obesity is a medical condition in which excess body fat has accumulated to an extent that it may have a negative effect on health. People are generally considered obese when their body mass index (BMI), a measurement obtained by dividing a person's weight by the square of the person's height, is over 30 kg/m2; the range 25–30 kg/m2 is defined as overweight. Some East Asian countries use lower values. Obesity increases the likelihood of various diseases and conditions, particularly cardiovascular diseases, type 2 diabetes, obstructive sleep apnea, certain types of cancer, osteoarthritis, and depression.

Cirrhosis long-term disease of the liver

Cirrhosis is a condition in which the liver does not function properly due to long-term damage. This damage is characterized by the replacement of normal liver tissue by scar tissue. Typically, the disease develops slowly over months or years. Early on, there are often no symptoms. As the disease worsens, a person may become tired, weak, itchy, have swelling in the lower legs, develop yellow skin, bruise easily, have fluid build up in the abdomen, or develop spider-like blood vessels on the skin. The fluid build-up in the abdomen may become spontaneously infected. Other complications include hepatic encephalopathy, bleeding from dilated veins in the esophagus or dilated stomach veins, and liver cancer. Hepatic encephalopathy results in confusion and may lead to unconsciousness.

The risk of gallstones may be decreased by maintaining a healthy weight through sufficient exercise and eating a healthy diet. [2] If there are no symptoms, treatment is usually not needed. [2] In those who are having gallbladder attacks, surgery to remove the gallbladder is typically recommended. [2] This can be carried out either through several small incisions or through a single larger incision, usually under general anesthesia. [2] In rare cases when surgery is not possible medication may be used to try to dissolve the stones or lithotripsy to break down the stones. [7]

Healthy diet diet that helps maintain or improve general health

A healthy diet is a diet that helps to maintain or improve overall health. A healthy diet provides the body with essential nutrition: fluid, macronutrients, micronutrients, and adequate calories.

Cholecystectomy surgical removal of the gallbladder

Cholecystectomy is the surgical removal of the gallbladder. Cholecystectomy is a common treatment of symptomatic gallstones and other gallbladder conditions. In 2011, cholecystectomy was the 8th most common operating room procedure performed in hospitals in the United States. Cholecystectomy can be performed either laparoscopically, using a video camera, or via an open surgical technique.

Lithotripsy is a medical procedure involving the physical destruction of hardened masses like kidney stones, bezoars or gallstones. The term is derived from the Greek words meaning "breaking stones".

In developed countries, 10–15% of adults have gallstones. [4] Rates in many parts of Africa, however, are as low as 3%. [8] Gallbladder and biliary related diseases occurred in about 104 million people (1.6%) in 2013 and they resulted in 106,000 deaths. [9] [10] Women more commonly have stones than men and they occur more commonly after the age of 40. [2] Certain ethnic groups have gallstones more often than others. [2] For example, 48% of Native Americans have gallstones. [2] Once the gallbladder is removed, outcomes are generally good. [2]

Race and health refers to how being identified with a specific race influences health. Race is a complex concept that changes across time and space and that depends on both self-identification and social recognition. In the study of race and health, scientists organize people in racial categories depending on different factors such as: phenotype, ancestry, social identity, genetic makeup and lived experience. “Race” and ethnicity often remain undifferentiated in health research.

Native Americans in the United States Indigenous peoples of the United States (except Hawaii)

Native Americans, also known as American Indians, Indigenous Americans and other terms, are the indigenous peoples of the United States, except Hawaii. There are over 500 federally recognized tribes within the US, about half of which are associated with Indian reservations. The term "American Indian" excludes Native Hawaiians and some Alaska Natives, while Native Americans are American Indians, plus Alaska Natives of all ethnicities. Native Hawaiians are not counted as Native Americans by the US Census, instead being included in the Census grouping of "Native Hawaiian and other Pacific Islander".

Definitions

Gallstone disease refers to the condition where gallstones are either in the gallbladder or common bile duct. [5] The presence of stones in the gallbladder is referred to as cholelithiasis, from the Greek chol- (bile) + lith- (stone) + -iasis (process). [1] If gallstones is in the common bile duct, the condition is referred to as choledocholithiasis, from the Greek chol- (bile) + docho- (duct) + lith- (stone) + iasis- (process). [1] Choledocholithiasis is frequently associated with obstruction of the bile ducts, which in turn can lead to cholangitis, from the Greek: chol- (bile) + ang- (vessel) + itis- (inflammation), a serious infection of the bile ducts. Gallstones within the ampulla of Vater can obstruct the exocrine system of the pancreas, which in turn can result in pancreatitis.

Common bile duct

The common bile duct, sometimes abbreviated CBD, is a duct in the gastrointestinal tract of organisms that have a gall bladder. It is formed by the union of the common hepatic duct and the cystic duct. It is later joined by the pancreatic duct to form the ampulla of Vater. There, the two ducts are surrounded by the muscular sphincter of Oddi.

Ascending cholangitis bile duct disease that is an inflammation of the bile duct

Ascending cholangitis, also known as acute cholangitis or simply cholangitis, is inflammation of the bile duct (cholangitis), usually caused by bacteria ascending from its junction with the duodenum. It tends to occur if the bile duct is already partially obstructed by gallstones.

Ampulla of Vater

The ampulla of Vater, also known as the hepatopancreatic ampulla or the hepatopancreatic duct, is formed by the union of the pancreatic duct and the common bile duct. The ampulla is specifically located at the major duodenal papilla.

Signs and symptoms

Gallstones Gallstones.png
Gallstones

Gallstones may be asymptomatic, even for years. These gallstones are called "silent stones" and do not require treatment. [11] [12] The size and number of gallstones present does not appear to influence whether people are symptomatic or asymptomatic. [13] A characteristic symptom of gallstones is a gallstone attack, in which a person may experience colicky pain in the upper-right side of the abdomen, often accompanied by nausea and vomiting. The pain steadily increases for approximately 30 minutes to several hours. A person may also experience referred pain between the shoulder blades or below the right shoulder. Often, attacks occur after a particularly fatty meal and almost always happen at night, and after drinking.

Biliary colic Medical condition in which gallstones cause acute pain

Biliary colic, also known as a gallbladder attack or gallstone attack, is when a colic occurs due to a gallstone temporarily blocking the cystic duct. Typically, the pain is in the right upper part of the abdomen. Pain usually lasts from one to a few hours. Often, it occurs after eating a heavy meal, or during the night. Repeated attacks are common.

Referred pain

Referred pain, also called reflective pain, is pain perceived at a location other than the site of the painful stimulus. An example is the case of angina pectoris brought on by a myocardial infarction, where pain is often felt in the neck, shoulders, and back rather than in the thorax (chest), the site of the injury. The International Association for the Study of Pain has not officially defined the term; hence several authors have defined it differently.

Scapula bone that connects the humerus (upper arm bone) with the clavicle (collar bone)

In anatomy, the scapula, also known as shoulder bone, shoulder blade, wing bone or blade bone, is the bone that connects the humerus with the clavicle. Like their connected bones the scapulae are paired, with the scapula on either side of the body being roughly a mirror image of the other. The name derives from early Roman times when it was thought that the bone resembled a trowel or small shovel.

In addition to pain, nausea, and vomiting, a person may experience a fever. If the stones block the duct and cause bilirubin to leak into the bloodstream and surrounding tissue, there may also be jaundice and itching. This can also lead to confusion. If this is the case, the liver enzymes are likely to be raised. [14]

Other complications

Rarely, gallstones in cases of severe inflammation may erode through the gallbladder into adherent bowel potentially causing an obstruction termed gallstone ileus. [15]

Other complications include ascending cholangitis if there is a bacterial infection which can cause purulent inflammation in the biliary tree and liver, and acute pancreatitis as blockage of the bile ducts can prevent active enzymes being secreted into the bowel, instead damaging the pancreas. [14] Rarely gallbladder cancer may occur as a complication. [6]

Risk factors

Gallstone risk increases for females (especially before menopause) and for people near or above 40 years; [16] the condition is more prevalent among both North and South Americans and among those of European descent than among other ethnicities. A lack of melatonin could significantly contribute to gallbladder stones, as melatonin inhibits cholesterol secretion from the gallbladder, enhances the conversion of cholesterol to bile, and is an antioxidant, which is able to reduce oxidative stress to the gallbladder. [17] Researchers believe that gallstones may be caused by a combination of factors, including inherited body chemistry, body weight, gallbladder motility (movement), and low calorie diet.[ citation needed ] The absence of such risk factors does not, however, preclude the formation of gallstones.

Nutritional factors that may increase risk of gallstones include constipation; eating fewer meals per day; low intake of the nutrients folate, magnesium, calcium, and vitamin C; [18] low fluid consumption; [19] and, at least for men, a high intake of carbohydrate, a high glycemic load, and high glycemic index diet. [20] Wine and whole-grained bread may decrease the risk of gallstones. [21]

Rapid weight loss increases risk of gallstones. [22] The weight loss drug orlistat is known to increase the risk of gallstones. [23]

Cholecystokinin deficiency caused by celiac disease increases risk of gallstone formation, especially when diagnosis of celiac disease is delayed. [24]

Pigment gallstones are most commonly seen in the developing world. Risk factors for pigment stones include hemolytic anemias (such as from sickle-cell disease and hereditary spherocytosis), cirrhosis, and biliary tract infections. [25] People with erythropoietic protoporphyria (EPP) are at increased risk to develop gallstones. [26] [27] Additionally, prolonged use of proton pump inhibitors has been shown to decrease gallbladder function, potentially leading to gallstone formation. [28]

Cholesterol modifying medications can affect gallstone formation. Statins inhibit cholesterol synthesis and there is evidence that their use may decrease the risk of getting gallstones. [29] [30] Fibrates increase cholesterol concentration in bile and their use has been associated with an increased risk of gallstones. [30]

Pathophysiology

Cholesterol gallstones develop when bile contains too much cholesterol and not enough bile salts. Besides a high concentration of cholesterol, two other factors are important in causing gallstones. The first is how often and how well the gallbladder contracts; incomplete and infrequent emptying of the gallbladder may cause the bile to become overconcentrated and contribute to gallstone formation. This can be caused by high resistance to the flow of bile out of the gallbladder due to the complicated internal geometry of the cystic duct. [31] The second factor is the presence of proteins in the liver and bile that either promote or inhibit cholesterol crystallization into gallstones. In addition, increased levels of the hormone estrogen, as a result of pregnancy or hormone therapy, or the use of combined (estrogen-containing) forms of hormonal contraception, may increase cholesterol levels in bile and also decrease gallbladder movement, resulting in gallstone formation.

Composition

From left to right: cholesterol stone, mixed stone, pigment stone. Types of Gallstones.jpg
From left to right: cholesterol stone, mixed stone, pigment stone.

The composition of gallstones is affected by age, diet and ethnicity. [32] On the basis of their composition, gallstones can be divided into the following types: cholesterol stones, pigment stones, and mixed stones. [3] An ideal classification system is yet to be defined. [33]

Cholesterol stones

Cholesterol stones vary from light yellow to dark green or brown or chalk white and are oval, usually solitary, between 2 and 3 cm long, each often having a tiny, dark, central spot. To be classified as such, they must be at least 80% cholesterol by weight (or 70%, according to the Japanese–classification system). [33] Between 35% and 90% of stones are cholesterol stones. [3]

Pigment stones

Bilirubin ("pigment", "black pigment") stones are small, dark (often appearing black), and usually numerous. They are composed primarily of bilirubin (insoluble bilirubin pigment polymer) and calcium (calcium phosphate) salts that are found in bile. They contain less than 20% of cholesterol (or 30%, according to the Japanese-classification system). [33] Between 2% and 30% of stones are bilirubin stones. [3]

Mixed stones

Mixed (brown pigment stones) typically contain 20–80% cholesterol (or 30–70%, according to the Japanese- classification system). [33] Other common constituents are calcium carbonate, palmitate phosphate, bilirubin and other bile pigments (calcium bilirubinate, calcium palmitate and calcium stearate). Because of their calcium content, they are often radiographically visible. They typically arise secondary to infection of the biliary tract which results in the release of β-glucuronidase (by injured hepatocytes and bacteria) which hydrolyzes bilirubin glucuronides and increases the amount of unconjugated bilirubin in bile. Between 4% and 20% of stones are mixed. [3]

Gallstones can vary in size and shape from as small as a grain of sand to as large as a golf ball. [34] The gallbladder may contain a single large stone or many smaller ones. Pseudoliths, sometimes referred to as sludge, are thick secretions that may be present within the gallbladder, either alone or in conjunction with fully formed gallstones.

Diagnosis

Diagnosis is typically confirmed by ultrasound. Other imaging techniques used are ERCP and MRCP. Gallstone complications may be detected on blood tests. [2]

A positive Murphy's sign is a common finding on physical examination during a gallbladder attack.

Prevention

Maintaining a healthy weight by getting sufficient exercise and eating a healthy diet that is high in fiber may help prevent gallstone formation. [2]

The medication ursodeoxycholic acid (UDCA) appears to prevent formation of gallstones during weight loss. [35] A high fat diet during weight loss also appears to prevent gallstones. [35]

Treatment

Surgical

Cholecystectomy (gallbladder removal) has a 99% chance of eliminating the recurrence of cholelithiasis. The lack of a gallbladder may have no negative consequences in many people. However, there is a portion of the population—between 10 and 15%—who develop a condition called postcholecystectomy syndrome [36] which may cause gastrointestinal distress and persistent pain in the upper-right abdomen, as well as a 10% risk of developing chronic diarrhea. [37]

There are two surgical options for cholecystectomy:

Medical

Cholesterol gallstones can sometimes be dissolved with ursodeoxycholic acid taken by mouth, but it may be necessary for the person to take this medication for years. [38] Gallstones may recur, however, once the drug is stopped. Obstruction of the common bile duct with gallstones can sometimes be relieved by endoscopic retrograde sphincterotomy (ERS) following endoscopic retrograde cholangiopancreatography (ERCP). Gallstones can be broken up using lithotripsy procedures, including laser lithotripsy and shock wave therapy. [38] These involve the breaking down of stones into tiny pieces that are then passed safely in the urine or feces.

Other animals

Gallstones can be a valued by-product of animals butchered for meat because of their use as a purported antipyretic and antidote in the folk remedies of some cultures, particularly, in China. The most highly prized gallstones tend to be sourced from old dairy cows, termed calculus bovis or niu-huang (yellow thing of cattle) in Chinese. Much as in the manner of diamond mines, some slaughterhouses carefully scrutinize workers for gallstone theft. [39]

See also

Related Research Articles

Bile duct

A bile duct is any of a number of long tube-like structures that carry bile, and is present in most vertebrates.

Cholecystitis cholangitis that is characterized by an inflammation that is located in the gallbladder

Cholecystitis is inflammation of the gallbladder. Symptoms include right upper abdominal pain, nausea, vomiting, and occasionally fever. Often gallbladder attacks precede acute cholecystitis. The pain lasts longer in cholecystitis than in a typical gallbladder attack. Without appropriate treatment, recurrent episodes of cholecystitis are common. Complications of acute cholecystitis include gallstone pancreatitis, common bile duct stones, or inflammation of the common bile duct.

Courvoisier's law states that in the presence of a palpably enlarged gallbladder which is nontender and accompanied with mild painless jaundice, the cause is unlikely to be gallstones. Usually, the term is used to describe the physical examination finding of the right-upper quadrant of the abdomen. This sign implicates possible malignancy of the gallbladder or pancreas and the swelling is unlikely due to gallstones.

Common bile duct stone Human disease

Common bile duct stone, also known as choledocholithiasis, is the presence of gallstones in the common bile duct (CBD). This condition can cause jaundice and liver cell damage. Treatment is by cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP).

Gallbladder cancer biliary tract cancer that is located in the gallbladder

Gallbladder cancer is a relatively uncommon cancer, with an incidence of fewer than 2 cases per 100,000 people per year in the United States. It is particularly common in central and South America, central and eastern Europe, Japan and northern India; it is also common in certain ethnic groups e.g. Native American Indians and Hispanics. If it is diagnosed early enough, it can be cured by removing the gallbladder, part of the liver and associated lymph nodes. Most often it is found after symptoms such as abdominal pain, jaundice and vomiting occur, and it has spread to other organs such as the liver.

Gallbladder disease gastrointestinal system disease that is located in the gallbladder

Gallbladder diseases are diseases involving the gallbladder.

Recurrent pyogenic cholangitis

Recurrent pyogenic cholangitis is characterised by recurrent bouts of bacterial cholangitis with primary hepatolithiasis. It is prevalent in Hong Kong and East Asian including China, Taiwan, Korea, Japan, Indonesia and the Philippines. Apart from affecting humans it is also a common disease in cats.

Cholescintigraphy

Cholescintigraphy or hepatobiliary scintigraphy is scintigraphy of the hepatobiliary tract, including the gallbladder and bile ducts. The image produced by this type of medical imaging, called a cholescintigram, is also known by other names depending on which radiotracer is used, such as HIDA scan, PIPIDA scan, DISIDA scan, or BrIDA scan. Cholescintigraphic scanning is a nuclear medicine procedure to evaluate the health and function of the gallbladder and biliary system. A radioactive tracer is injected through any accessible vein and then allowed to circulate to the liver, where it is excreted into the bile ducts and stored by the gallbladder until released into the duodenum.

Biliary dyskinesia is a disorder of some component of biliary part of the digestive system in which bile physically can not move normally in the proper direction through the tubular biliary tract. It most commonly involves abnormal biliary tract peristalsis muscular coordination within the gallbladder in response to dietary stimulation of that organ to squirt the liquid bile through the common bile duct into the duodenum. Ineffective peristaltic contraction of that structure produces postprandial right upper abdominal pain (cholecystodynia) and almost no other problem. When the dyskinesia is localized at the biliary outlet into the duodenum just as increased tonus of that outlet sphincter of Oddi, the backed-up bile can cause pancreatic injury with abdominal pain more toward the upper left side. In general, biliary dyskinesia is the disturbance in the coordination of peristaltic contraction of the biliary ducts, and/or reduction in the speed of emptying of the biliary tree into the duodenum.

Sphincter of Oddi dysfunction Sphincter of Oddi

Sphincter of Oddi dysfunction refers to a group of functional disorders leading to abdominal pain due to dysfunction of the Sphincter of Oddi: functional biliary sphincter of Oddi and functional pancreatic sphincter of Oddi disorder. The sphincter of Oddi is a sphincter muscle, a circular band of muscle at the bottom of the biliary tree which controls the flow of pancreatic juices and bile into the second part of the duodenum. The pathogenesis of this condition is recognized to encompass stenosis or dyskinesia of the sphincter of Oddi ; consequently the terms biliary dyskinesia, papillary stenosis, and postcholecystectomy syndrome have all been used to describe this condition. Both stenosis and dyskinesia can obstruct flow through the sphincter of Oddi and can therefore cause retention of bile in the biliary tree and pancreatic juice in the pancreatic duct.

Technetium (<sup>99m</sup>Tc) mebrofenin chemical compound

Technetium (99mTc) mebrofenin is a diagnostic radiopharmaceutical used for imaging of the liver and the gallbladder. Under the brand name Choletec it is available from Bracco Diagnostic. Supplied as a sterile kit of mebrofenin and dehydrated stannous fluoride. The vial is reconstituted with 1 to 5 mL up to 3.7 gigabecquerels (100 mCi) of sodium pertechnetate solution to form the final radio labeled 99mTc mebrofenin.

Biliary sludge disease

Biliary sludge refers to a viscous mixture of small particles derived from bile. These sediments consist of cholesterol crystals, calcium salts, calcium bilirubinate, mucin, and other materials.

Adenomyomatosis

Adenomyomatosis is a benign condition characterized by hyperplastic changes of unknown cause involving the wall of the gallbladder. Adenomyomatosis is caused by an overgrowth of the mucosa, thickening of the muscular wall, and formation of intramural diverticula or sinus tracts termed Rokitansky–Aschoff sinuses, also called entrapped epithelial crypts.

The gallbladder flush or liver cleanse is an alternative medicine practice involving fasting, followed by the ingestion of some combination of Epsom salt, olive oil, and grapefruit juice, in some cases substituted by other, similar ingredients. Those who advocate it claim that it is possible to remove not only the well-known gallstones from the gallbladder, but also the so-called intra-hepatic stones from the bile ducts of the liver by this procedure.

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Classification
D
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