Gallstones

What are gallstones?

Think of your gallbladder as a way station, a place where bile (a thick greenish-yellow digestive juice) from your liver is stored. When your body needs bile to help absorb fat, the gallbladder propels bile into your intestines. Bile contains a mix of cholesterol, calcium, and bilirubin, a waste product from old blood cells. If too much of one of these builds up, crystals form, clump together, and enlarge into gallstones. A gallstone can be as tiny as a grain of sand or as big as a golf ball.

Odds are, you won’t have symptoms and will learn about your gallstones during another test (a chest x-ray often includes the gallbladder). Although these “silent gallstones” are generally harmless, they can create problems. If a gallstone tries to squeeze through the narrow duct from your gallbladder to your small intestine, you’ll have severe pain until it passes. A more serious condition called acute cholecystitis occurs when the stone can’t pass: This creates a blockage and sometimes even a potentially life-threatening infection in the gallbladder or the duct. Acute cholecystitis will respond to antibiotics once the stone passes or is removed.

If you have an infection or a blocked duct, you’ll know it. Pain that starts in your upper right abdomen that may radiate to your back or right shoulder, and if you breathe deeply, it gets worse. Pain that comes in waves is called colic: Your duct is struggling to pass a gallstone. If the pain is more constant, and the areas are tender, acute cholecystitis may be the problem. Gallbladder flare-ups frequently occur after eating a large or fatty meal. Bloating, nausea, and vomiting may also be present. Warning signs of a prolonged blockage are a high fever, jaundice, and constant pain.

Who is at risk for gallstones?

Just why some people develop gallstones is a mystery. Every medical student knows the profile of an at-risk person as the five “Fs”: someone who is Fair (light complexion), Female (estrogen boosts cholesterol secretion), Fat (excess weight also ups cholesterol output), Fertile (previous pregnancies), and older than Forty. Other risks include a history of crash dieting, diabetes, or an inflammatory bowel condition.

Treatment for gallstones

If you have gallstones but don’t have symptoms, your doctor will probably recommend a wait-and-see approach. Most mild, intermittent symptoms respond to certain lifestyle changes: following a low-fat diet and losing some weight. If you’ve passed one gallstone and x-rays show more are present, your doctor will likely suggest surgery. If you are having symptoms of acute cholecystitis, with constant pain and fever, your doctor will want you hospitalized for intravenous antibiotics and pain control. For recurring attacks, or after an episode of acute cholecystitis that has “cooled down” with antibiotics, your doctor may advise surgical removal of the gallbladder, a process greatly simplified by laparoscopic procedures.

Medications for gallstones

If you have intense pain in your upper abdomen, call your doctor right away or go to an emergency room. You’ll probably be put on intravenous (IV) medications, which may include a painkiller such as meperidine (Demerol) or pentazocine (Talwin), drugs to stop your vomiting, and if you have signs of an infection, antibiotics. You’ll get electrolytes and fluids by IV. If your pain clears up and lab tests don’t reveal any complications, you’re likely to be sent home with oral painkillers, and perhaps antibiotics. Schedule a conversation with your doctor regarding surgery.

There is medication to dissolve gallstones, ursodeoxycholic acid or ursodiol (Actigall). It’s not widely used, because it’s expensive and effective in only about 10% of cases. If you really want to avoid surgery (or have serious health concerns that rule it out), your doctor may recommend this drug, which is taken orally and dissolves the gallstones over a period of one to two years. It works only if your gallstones are small and composed of cholesterol. A word of warning: Because there’s about a 50% chance of recurrence within five years, you may need long-term, low-dose maintenance.

Lifestyle Changes

The top priority of most people who’ve passed a gallstone is to keep it from happening again. You can reduce the number of repeat episodes (and maybe even prevent them) by doing the following:

• Watch your weight. An ideal body weight can help keep gallstones from forming. If you need to shed pounds, don’t lose too much too fast: Rapid weight loss increases gallstone production.
• Reduce dietary fat and sugar. Both have been linked to an increased risk for gallstones. Instead, eat a diet rich in fruits and vegetables; vegetarians infrequently get gallstones.
• Drink plenty of fluids. At least six to eight glasses a day will help you maintain the right water content for bile.
• Stay regular. Eating fibre-rich foods is always helpful. For occasional constipation, use a bulk-forming laxative, such as psyllium (Metamucil) or calcium polycarbophil (FiberCon).
• Exercise. Try to get 30 minutes of aerobic exercise—jogging, swimming, biking, playing tennis, brisk walking—at least three to five times a week.

Related Procedures for Gallstones

For gallstones that cause problems, the most common treatment is surgery to remove the source—your gallbladder, a procedure called a cholecystectomy. Until 1990, it was done via a long abdominal incision, in an operation called an open cholecystectomy. Today, some 90% of gallbladder removals are performed with a less invasive technique called a laparoscopic cholecystectomy, known as a “lap choly”. Four small incisions are made in the abdomen. Then the gallbladder is removed, using a tiny video camera and flexible surgical instruments. If problems occur, the surgeon can revert to a conventional open cholecystectomy.

With a lap choly, you’ll need to stay in the hospital for only a day (sometimes even less if you have outpatient surgery), vs. five days after open surgery. Your recovery time should be short; many people are back at their regular activities within a week. (Traditional surgery has a four- to six-week recovery period.) Under most circumstances, surgery is elective, meaning you can decide when you want it done. But if you’re hospitalized and tests indicate that you have a serious complication, such as an abscess or gallbladder perforation, you’ll need surgery immediately.

If your doctor suspects that you have a gallstone stuck in a bile duct but no infection, he may recommend an endoscopic retrograde cholangiopancreatography (ERCP). In this procedure, a flexible viewing tube with surgical attachments is passed through your mouth, esophagus, and stomach to your small intestine and into the tiny opening where the bile duct enters. Your doctor can actually see the gallstone for himself, grasp it with surgical instruments, and remove it from the duct.

A small number of people may be able to treat their gallstones with procedures less invasive than surgery. One involves ultrasound waves (a process called extracorporeal shock wave lithotripsy) that pulverize gallstones, so they’re small enough to pass through bile ducts or be dissolved with medication. To be a candidate, you must have only one small stone and a healthy gallbladder. Doctors recommend it only in rare cases, because stones have a 50% chance of recurring in five years. Another procedure, only for small gallstones, infuses a solvent directly into your gallbladder via a long, thin needle. The solvent, methyl tert-butyl ether (MTBE), dissolves cholesterol gallstones in a day or two. As with other nonsurgical remedies, recurrence is a possibility.

Questions for Your Doctor

• Is it possible that my abdominal pain is not from gallstones? Could it be caused by a peptic ulcer or pancreatitis?
• If I improve my diet, will the gallstones eventually dissolve on their own?
• Should I take a painkiller like aspirin or Tylenol when gallstone pain hits?

Living with Gallstones

If you have Gallstones, here’s a few quick tips to help you take control:

• Keep moving if you’re having a gallstone attack. After you’ve called your doctor, you may be able to make yourself more comfortable by walking or lying on a bed and rolling from side to side.
• Be alert for abdominal pain even after your gallbladder is removed. Gallstones can still form in your bile ducts. If you feel pain in your upper abdomen, notify your doctor.
• Shun the sun. There may be a link between prolonged sun exposure and gallstone development. Avoid sunbathing if you are in any way at risk for developing gallstones.