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What are gallstones?
Gallstones are small, pebble-like substances that
develop in the gallbladder. The gallbladder is a small, pear-shaped sac located
below your liver in the right upper abdomen. Gallstones form when liquid
stored in the gallbladder hardens into pieces of stone-like material. The
the body digest fats. Bile is made in the liver, then
stored in the gallbladder until the body needs it. The gallbladder
contracts and pushes the bile into a tube—called
the common bile duct—that carries it to the small
intestine, where it helps with digestion.
Bile contains water, cholesterol, fats, bile salts,
proteins, and bilirubin—a
waste product. Bile salts break up fat, and bilirubin
gives bile and stool a yellowish-brown color. If the liquid bile contains
too much cholesterol, bile salts, or bilirubin,
it can harden into gallstones.
The two types of gallstones are cholesterol stones and
pigment stones. Cholesterol stones are usually yellow-green and are made
primarily of hardened cholesterol. They account for about 80 percent of
gallstones. Pigment stones are small, dark stones made of bilirubin. Gallstones can be as small as a grain of
sand or as large as a golf ball. The gallbladder can develop just one large
stone, hundreds of tiny stones, or a combination of the two.
gallbladder and the ducts that carry bile and other digestive enzymes from
the liver, gallbladder, and pancreas to the small intestine are called the biliary system.
Gallstones can block the normal flow of bile if they
move from the gallbladder and lodge in any of the ducts that carry bile
from the liver to the small intestine. The ducts include the
ducts, which carry bile out of the liver
duct, which takes bile to and from the gallbladder
bile duct, which takes bile from the cystic and hepatic ducts to the
Bile trapped in these ducts can cause inflammation in
the gallbladder, the ducts, or in rare cases, the liver. Other ducts open into
the common bile duct, including the pancreatic duct, which carries
digestive enzymes out of the pancreas. Sometimes gallstones passing through
the common bile duct provoke inflammation in the pancreas—called gallstone pancreatitis—an extremely painful and potentially dangerous condition.
If any of the bile ducts remain blocked for a
significant period of time, severe damage or infection can occur in the
gallbladder, liver, or pancreas. Left untreated, the condition can be
fatal. Warning signs of a serious problem are fever, jaundice, and
What causes gallstones?
Scientists believe cholesterol stones form when bile contains
too much cholesterol, too much bilirubin, or not
enough bile salts, or when the gallbladder does not empty completely or
often enough. The reason these imbalances occur is not known.
The cause of pigment stones is not fully understood.
The stones tend to develop in people who have liver cirrhosis, biliary tract infections, or hereditary blood disorders—such as sickle cell anemia—in which the
liver makes too much bilirubin.
The mere presence of gallstones may cause more
gallstones to develop. Other factors that contribute to the formation of
gallstones, particularly cholesterol stones, include
Sex. Women are
twice as likely as men to develop gallstones. Excess estrogen from
pregnancy, hormone replacement therapy, and birth control pills appears to
increase cholesterol levels in bile and decrease gallbladder movement,
which can lead to gallstones.
Family history. Gallstones often run in families, pointing to a possible
large clinical study showed that being even moderately overweight increases
the risk for developing gallstones. The most likely reason is that the
amount of bile salts in bile is reduced, resulting in more cholesterol.
Increased cholesterol reduces gallbladder emptying. Obesity is a major risk
factor for gallstones, especially in women.
high in fat and cholesterol and low in fiber increase the risk of
gallstones due to increased cholesterol in the bile and reduced gallbladder
Rapid weight loss. As the body metabolizes fat during prolonged fasting and rapid
weight loss—such as “crash
diets”—the liver secretes extra cholesterol into
bile, which can cause gallstones. In addition, the gallbladder does not
older than age 60 are more likely to develop gallstones than younger
people. As people age, the body tends to secrete more cholesterol into
American Indians have a genetic predisposition to secrete high levels of
cholesterol in bile. In fact, they have the highest rate of gallstones in
the United States.
The majority of American Indian men have gallstones by age 60. Among the
Pima Indians of Arizona, 70 percent of women have gallstones by age 30.
Mexican American men and women of all ages also have high rates of
Cholesterol-lowering drugs. Drugs that lower cholesterol levels in the blood actually
increase the amount of cholesterol secreted into bile. In turn, the risk of
People with diabetes generally have high levels of fatty acids called
triglycerides. These fatty acids may increase the risk of gallstones.
Who is at risk for gallstones?
People at risk for gallstones include
- women—especially women who are pregnant, use hormone replacement
therapy, or take birth control pills
over age 60
or obese men and women
who fast or lose a lot of weight quickly
with a family history of gallstones
who take cholesterol-lowering drugs
What are the symptoms of gallstones?
As gallstones move into the bile ducts and create
blockage, pressure increases in the gallbladder and one or more symptoms
may occur. Symptoms of blocked bile ducts are often called a gallbladder “attack” because they occur suddenly.
Gallbladder attacks often follow fatty meals, and they may occur during the
night. A typical attack can cause
pain in the right upper abdomen that increases rapidly and lasts from
30 minutes to several hours
in the back between the shoulder blades
under the right shoulder
Notify your doctor if you think you have experienced a
gallbladder attack. Although these attacks often pass as gallstones move,
your gallbladder can become infected and rupture if a blockage remains.
People with any of the following symptoms
should see a doctor immediately:
pain—more than 5 hours
- fever—even low-grade—or chills
color of the skin or whites of the eyes
Many people with gallstones have no symptoms; these
gallstones are called “silent stones.” They do not interfere with gallbladder, liver, or pancreas
function and do not need treatment.
How are gallstones diagnosed?
Frequently, gallstones are discovered during tests for
other health conditions. When gallstones are suspected to be the cause of
symptoms, the doctor is likely to do an ultrasound exam梩he most sensitive and specific test for gallstones. A handheld
device, which a technician glides over the abdomen, sends sound waves
toward the gallbladder. The sound waves bounce off the gallbladder, liver,
and other organs, and their echoes make electrical impulses that create a
picture of the gallbladder on a video monitor. If gallstones are present,
the sound waves will bounce off them, too, showing their location. Other
tests may also be performed.
Computerized tomography (CT)
scan. The CT scan is a noninvasive
x ray that produces cross-section images of the body. The test may show the
gallstones or complications, such as infection and rupture of the
gallbladder or bile ducts.
Cholescintigraphy (HIDA scan). The patient is injected with a small amount of nonharmful radioactive material that is absorbed by the
gallbladder, which is then stimulated to contract. The test is used to
diagnose abnormal contraction of the gallbladder or obstruction of the bile
Endoscopic retrograde cholangiopancreatography (ERCP). ERCP is used to locate and remove stones in the bile ducts.
After lightly sedating you, the doctor inserts an endoscope梐 long, flexible, lighted tube with a camera梔own the throat and through the stomach and into the small
intestine. The endoscope is connected to a computer and video monitor. The
doctor guides the endoscope and injects a special dye that helps the bile
ducts appear better on the monitor. The endoscope helps the doctor locate
the affected bile duct and the gallstone. The stone is captured in a tiny
basket and removed with the endoscope.
Blood tests may be performed to look for signs of infection, obstruction, pancreatitis, or jaundice.
Because gallstone symptoms may be similar to those of a
heart attack, appendicitis, ulcers, irritable bowel syndrome, hiatal hernia, pancreatitis,
and hepatitis, an accurate diagnosis is important.
How are gallstones treated?
If you have gallstones without symptoms, you do not
require treatment. If you are having frequent gallbladder attacks, your
doctor will likely recommend you have your gallbladder removed—an operation called a cholecystectomy.
Surgery to remove the gallbladder—a nonessential
organ—is one of the most common surgeries performed
on adults in the United States.
Nearly all cholecystectomies
are performed with laparoscopy. After giving you medication to sedate you,
the surgeon makes several tiny incisions in the abdomen and inserts a
laparoscope and a miniature video camera. The camera sends a magnified
image from inside the body to a video monitor, giving the surgeon a
close-up view of the organs and tissues. While watching the monitor, the
surgeon uses the instruments to carefully separate the gallbladder from the
liver, bile ducts, and other structures. Then the surgeon cuts the cystic
duct and removes the gallbladder through one of the small incisions.
Recovery after laparoscopic surgery usually involves
only one night in the hospital, and normal activity can be resumed after a
few days at home. Because the abdominal muscles are not cut during
laparoscopic surgery, patients have less pain and fewer complications than
after “open” surgery, which
requires a 5- to 8-inch incision across the abdomen.
If tests show the gallbladder has severe inflammation,
infection, or scarring from other operations, the surgeon may perform open
surgery to remove the gallbladder. In some cases, open surgery is planned;
however, sometimes these problems are discovered during the laparoscopy and
the surgeon must make a larger incision. Recovery from open surgery usually
requires 3 to 5?days in the hospital and several
weeks at home. Open surgery is necessary in about 5?percent
of gallbladder operations.
The most common complication in gallbladder surgery is
injury to the bile ducts. An injured common bile duct can leak bile and
cause a painful and potentially dangerous infection. Mild injuries can
sometimes be treated nonsurgically. Major injury,
however, is more serious and requires additional surgery.
If gallstones are present in the bile ducts, the
physician—usually a gastroenterologist—may use ERCP to locate and remove them before or during
gallbladder surgery. Occasionally, a person who has had a cholecystectomy is diagnosed with a gallstone in the
bile ducts weeks, months, or even years after the surgery. The ERCP
procedure is usually successful in removing the stone in these cases.
Nonsurgical approaches are used only in special situations—such as when a patient has a serious medical condition
preventing surgery—and only for cholesterol stones.
Stones commonly recur within 5 years in patients treated nonsurgically.
Oral dissolution therapy. Drugs made from bile acid are used to dissolve gallstones. The
drugs ursodiol (Actigall)
and chenodiol (Chenix)
work best for small cholesterol stones. Months or years of treatment may be
necessary before all the stones dissolve. Both drugs may cause mild
diarrhea, and chenodiol may temporarily raise
levels of blood cholesterol and the liver enzyme transaminase.
Contact dissolution therapy. This experimental procedure involves injecting a drug directly
into the gallbladder to dissolve cholesterol stones. The drug—methyl tert-butyl ether—can dissolve some stones in 1 to 3 days, but it causes
irritation and some complications have been reported. The procedure is
being tested in symptomatic patients with small stones.
Do people need their gallbladder?
Fortunately, the gallbladder is an organ people can
live without. Your liver produces enough bile to digest a normal diet. Once
the gallbladder is removed, bile flows out of the liver through the hepatic
ducts into the common bile duct and directly into the small intestine,
instead of being stored in the gallbladder. Because now the bile flows into
the small intestine more often, softer and more frequent stools can occur
in about 1 percent of people. These changes are usually temporary, but talk
with your health care provider if they persist.
Points to Remember
form when bile hardens in the gallbladder.
are more common among older adults; women; American Indians; Mexican
Americans; people with diabetes; those with a family history of gallstones;
people who are overweight, obese, or undergo rapid weight loss; and
those taking cholesterol-lowering drugs.
attacks often occur after eating a meal, especially one high in fat.
can mimic those of other problems, including a heart attack, so an
accurate diagnosis is important.
can cause serious problems if they become trapped in the bile ducts.
surgery to remove the gallbladder is the most common treatment.
Hope through Research
Animal research has helped identify several genes that
may determine which people are more prone to gallstones. In spite of many
well-defined risk factors for gallstones, researchers continue to look for
genes that may identify susceptibility in humans. Researchers also believe
that the growing global epidemic of obesity may increase rates of
gallbladder disease worldwide.
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For More Information
American Academy of Family Physicians
P.O. Box 11210
Shawnee Mission, KS 66207–1210
Phone: 1–800–274–2237 or 913–906–6000
American Gastroenterological Association
4930 Del Ray Avenue
Bethesda, MD 20814
International Foundation for Functional Gastrointestinal Disorders
P.O. Box 170864
Milwaukee, WI 53217–8076
Phone: 1–888–964–2001 or 414–964–1799
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