Gallstone

Gallstone

gallstones
ICD-10	K80
ICD-O:
ICD-9	574
OMIM	600803
MedlinePlus	000273
eMedicine	emerg/97
DiseasesDB	2533

Gall bladder opened to show numerous gallstones. Their brownish to greenish color suggest they are cholesterol calculi.

A gallstone is a hard, solid crystalline mass that forms within the body by accretion or concretion of normal or abnormal bile components. Gallstones most commonly form in the gallbladder, but can occur anywhere within the biliary tree, including the the common bile duct that leads into the first portion of the small intestine. Gallstones can migrate to various parts of the digestive system and cause severe pain and life-threatening complications (Haggerty 2002). Gallstones vary in size, ranging from being as small as a grain of sand to as large as a golf ball (Haggerty 2002). They also vary in chemical composition, with eighty percent composed of cholesterol, but bile pigments and calcium salts also may be involved.

Gallstones are the fifth most common cause of hospitalization in the United States, with about twenty percent of pepole over 60 having either one large stone or even several thousand small ones (Haggerty 2002). However, only about one to three percent develop symptoms (WebMD 2008). Gallstones are the most common disease of the gallbladder and bile duct (Haggery 2002).

Gallstones result from the alteration in the chemical composition of bile, such as an excessive increase in concentration of cholesterol (Breslow 2002; Haggery 2002). Dietary factors are important, as it correlates with fatty diets, obesity, high blood cholesterol levels, smoking, and diabetes, as well as pregnancy (Kent 2002)

Overview

Gallstones are a concretion formed from bile. Bile is a thick, greenish-yellow fluid that assists in digestion, and in most vertebrates is made in the liver and stored in the gallbladder between meals. The human liver produces about a quart (or liter) of bile per day. In species with a gallbladder (including humans and most domestic animals, but not horses or rats), further modification of bile occurs in this organ. The gallbladder stores and concentrates bile during the fasting state (between meals). Typically, bile is concentrated five-fold in the gallbladder by absorption of water and small electrolytes. Virtually all of the organic molecules are retained. When fats are present in the digestive tract after the consumption of a meal, a hormonal signal causes the gallbladder to contract and release bile in to the small intestine. The biliary tree or biliary system refers to the path by which bile is secreted by the liver on its way to the duodenum, or small intestine, of most members of the mammal family, and includes the liver, gallbladder, pancrease, and various ducts, such as the common bile duct leading to the small intestine.

Among the components of bile are water, cholesterol, lecithin, bile pigments (bilirubin and biliverdin), and bile salts and bile acids. Gallstones typically are composed of cholesterol—cholesterol stones make up about eighty percent of all gallstones (WebMD 2008). Bile pigments and calcium salts may also be involved. Pigments stones are less common and from when bilirubin precipitates in bile (Breslow 2002; WebMD 2008).

Gallstones often cause no symptoms. However if they are large, or many, or move into areas where they cause blockage of a duct, whether those connecting the liver, gallbladder, or pancreas with the intestine, then there can be serious complications, incluidng inflammation, severe pain, organ damage, and death (WebMD 2008).

There are several disorders associated with gallstones. Cholelithiasis is the presence of stones in the gallbladder. (Chole- means "bile," lithia means "stone," and -sis means "process.") Obstruction of the common bile duct is known as choledocholithiasis. Cholecystitis is inflammation of the gallbladder and is usually caused by a gallstone passing from the gallbladder to the cystic duct, but in five to ten percent of the cases a gallstone is not the cause (Haggerty 2002). Gallstone ileus results from the blockage fo the entrance to the large intestine caused by a gallstone. Obstruction of the biliary tree can cause jaundice; obstruction of the outlet of the pancreatic exocrine system can cause pancreatitis.

Characteristics of gallstones

A gallstone's size varies and may be as small as a sand grain or as large as a golf ball. The gallbladder may develop a single, often large, stone or many smaller ones. They may occur in any part of the biliary system.

Content

Gallstones have different appearance, depending on their contents. On the basis of their contents, gallstones can be subdivided into the two following types:

Cholesterol stones

Gallstones

Cholesterol stones are usually green, but are sometimes white or yellow in color. They are made primarily of cholesterol.

Pigment stones

Pigment stones are small, dark stones made of bilirubin and calcium salts that are found in bile. They account for the other 20 percent of gallstones. Risk factors for pigment stones include hemolytic anemia, cirrhosis, biliary tract infections, and hereditary blood cell disorders, such as sickle cell anemia and spherocytosis.

Mixed stones

Mixed stones account for the majority of stones. Most of these are a mixture of cholesterol and calcium salts. Because of their calcium content, they can often be visualized radiographically.

Pseudolithiasis

A.K.A. "Fake stone" Sludge-like gallbladder secretions that act like a stone.

Causes

Progress has been made in understanding the process of gallstone formation. Researchers believe that gallstones may be caused by a combination of factors, including inherited body chemistry, body weight, gallbladder motility (movement), and perhaps diet. Additionally, people with erythropoietic protoporphyria (EPP) are at increased risk to develop gallstones.

Cholesterol gallstones develop when bile contains too much cholesterol and not enough bile salts. Besides a high concentration of cholesterol, two other factors seem to be 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. 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, 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.

No clear relationship has been proven between diet and gallstone formation. However, low-fibre, high-cholesterol diets, and diets high in starchy foods have been suggested as contributing to gallstone formation. Other nutritional factors that may increase risk of gallstones include rapid weight loss, constipation, eating fewer meals per day, eating less fish, and low intakes of the nutrients folate, magnesium, calcium, and vitamin C. On the other hand, wine and whole grain bread may decrease the risk of gallstones.

Symptoms

Gall stones usually remain asymptomatic initially. They start developing symptoms once the stones reach a certain size (>8mm). A main symptom of gallstones is commonly referred to as a gallstone "attack", also known as biliary colic, in which a person will experience intense pain in the upper abdominal region that steadily increases for approximately thirty minutes to several hours. A victim may also encounter pain in the back, ordinarily between the shoulder blades, or pain under the right shoulder. In some cases, the pain develops in the lower region of the abdomen, nearer to the pelvis, but this is less common.^{[citation needed]} Nausea and vomiting may occur.

These attacks are sharp and intensely painful, similar to that of a kidney stone attack. One way to alleviate the abdominal pain is to drink a full glass of water at the start of an attack to regulate the bile in the gallbladder, but this does not work in all cases.^{[citation needed]} Another way is to take magnesium followed by a bitter liquid such as coffee or swedish bitters an hour later.^{[citation needed]} Bitter flavors stimulate bile flow.^{[citation needed]} A study has found lower rates of gallstones in coffee drinkers.

Often, these attacks occur after a particularly fatty meal and almost always happen at night. Other symptoms include abdominal bloating, intolerance of fatty foods, belching, gas, and indigestion. If the above symptoms coincide with chills, lowgrade fever, yellowing of the skin or eyes, and/or clay-colored stool, a doctor should be consulted immediately.

Some people who have gallstones are asymptomatic and do not feel any pain or discomfort. These gallstones are called "silent stones" and do not affect the gallbladder or other internal organs. They do not need treatment.

Treatment

Medical options

Cholesterol gallstones can sometimes be dissolved by oral ursodeoxycholic acid. 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 cholangiopancretaography (ERCP). A common misconception is that the use of ultrasound (Extracorporeal Shock Wave Lithotripsy) can be used to break up gallstones.^{[citation needed]} Although this treatment is highly effective against kidney stones, it can only rarely be used to break up the softer and less brittle gallstones.

Surgical options

Cholecystectomy (gallbladder removal) has a 99% chance of eliminating the recurrence of cholelithiasis. Only symptomatic patients must be indicated to surgery. The lack of a gall bladder does not seem to have any negative consequences in many people. However, there is a significant proportion of the population, between 5-40%, who develop a condition called postcholecystectomy syndrome.Symptoms include gastrointestinal distress and persistent pain in the upper right abdomen. 20% of patients develop chronic diarrhea.

There are two surgery options: open procedure and laparoscopic: see the cholecystectomy article for more details.

• Open cholecystectomy procedure: This involves a large incision into the abdomen (laparotomy) below the right lower ribs. A week of hospitalization, normal diet a week after release and normal activity a month after release.
• Laparoscopic cholecystectomy: 3-4 small puncture holes for camera and instruments (available since the 1980s). Typically same-day release or one night hospital stay, followed by a week of home rest and pain medication. Can resume normal diet and light activity a week after release. (Decreased energy level and minor residual pain for a month or two.) Studies have shown that this procedure is as effective as the more invasive open cholecystectomy, provided the stones are accurately located by cholangiogram prior to the procedure so that they can all be removed. The procedure also has the benefit of reducing operative complications such as bowel perforation and vascular injury.

Alternative medicine

A regimen called a "gallbladder flush" or "liver flush" is a popular remedy in alternative medicine. In this treatment, often self-administered, the patient drinks four glasses of pure apple juice (not cider) and eats five apples (or applesauce) per day for five days, then fasts briefly, takes magnesium, and then drinks large quantities of lemon juice mixed with olive oil before bed. The next morning, they painlessly pass a number of green and brown pebbles purported to be stones flushed from the biliary system.

A New Zealand hospital analyzed stones from a typical gallbladder flush and found them to be composed of fatty acids similar to those in olive oil, with no detectable cholesterol or bile salts, demonstrating that they are little more than hardened olive oil. Despite the gallbladder flush, the patient still required surgical removal of multiple true gallstones. The note concluded: "The gallbladder flush may not be entirely worthless, however; there is one case report in which treatment with olive oil and lemon juice resulted in the passage of numerous gallstones, as demonstrated by ultrasound examination."

In the case mentioned, ultrasound confirmed multiple gallstones, but after waiting months for a surgical option, the patient underwent a treatment with olive oil and lemon juice resulting in the passage of four 2.5 cm by 1.25 cm stones and twenty pea-sized stones. Two years later symptoms returned, and ultrasound showed a single large gallstone; the patient chose to have this removed surgically.

Value

Gallstones are, oddly, a valuable by-product of meat processing, fetching up to US$32 per gram in their use as a purported antipyretic and antidote in the herbal medicine of some cultures, particularly in China. The finest gallstones tend to be sourced from old dairy cows, which are called Niu-Huang (yellow thing of oxen) in Chinese. Those got from dogs, called Gou-Bao (treasure of dogs) in Chinese, are also used today. Much as in the manner of diamond mines, slaughterhouses carefully scrutinize offal department workers for gallstone theft.

References

ISBN links support NWE through referral fees

• Bender, D. A., and A. E. Bender. 2005. A Dictionary of Food and Nutrition. New York: Oxford University Press. ISBN 0198609612.

• Breslow, L. 2002. Encyclopedia of Public Health. New York: Macmillan Reference USA/Gale Group Thomson Learning. ISBN 0028658884.

• Haggerty, M. Gallstones. 2002. Pages 1387-1391 in J. L. Longe, ed., The Gale Encyclopedia of Medicine, 2nd edition, vol. 3. Detroit, MI: Gale Group/Thomson Learning. ISBN 0787654922.

• Kent, M. 2002. Food and Fitness: A Dictionary of Diet and Exercise. Oxford reference online. Oxford: Oxford University Press. ISBN 0198631472.

WebMD. 2008. http://www.emedicinehealth.com/gallstones/article_em.htm Gallstones

External links

• Public domain NIH/NIDDK e-pub on gallstones
• Gallbladder removal - series from Nuggets Medical Encyclopedia
• "Gall Stones and Gall Bladder Surgery" Information for this article was located from the University of Florida, Medical Library in Gainesville, Florida, and researched by Richard Pressinger (M.Ed.) and Jerry Abraham (M.B.A)

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