Gallstones

Definition

Gallstones are solid crystal deposits that form in the gallbladder, a pear-shaped organ that stores bile until it is needed to help digest fatty foods. These crystals can migrate to other parts of the digestive tract, causing severe pain and life-threatening complications. Gallstones vary in size and chemical structure. They may be as tiny as a grain of sand, or as large as a golf ball.

Description

Gallstones usually develop in adults between the ages of 20 and 50. The risk of developing gallstones increases with age. Young women are up to six times more likely to develop gallstones than men in the same age group. In patients over 50, however, the condition affects men and women with equal frequency. Native Americans develop gallstones more often than any other segment of the population, and Mexican Americans have the second highest incidence of this disease. Gallstones tend to be passed down genetically in families.

Eighty percent of gallstones are composed of cholesterol . They are formed when the liver produces more cholesterol than the digestive juices can liquefy. The remaining 20% of gallstones are composed of calcium and an orange-yellow waste product called bilirubin, which gives urine its characteristic color and sometimes causes jaundice .

People who have gallstones may remain without symptoms for an extended period, especially if the stones remain in the gallbladder. In most cases, medical treatment is only deemed necessary if the individual is experiencing symptoms. When symptoms do appear, it is usually because the stones have left the gallbladder and are stuck somewhere else within the biliary system, blocking the flow of bile. If gallstones remain stuck in the biliary system, there can be damage to the liver, pancreas, or the gallbladder itself.

Gallstones bring on several disorders including:

• Cholelithiasis: Gallstones within the gallbladder itself. Pain is caused by the contractions of the gallbladder around the stone.
• Choledocholithiasis: The presence of gallstones within the common bile duct, which is the passage between that empties into the small intestine. Once discovered, common duct stones need to be removed in order to avoid further problems.
• Cholecystitis: A disorder marked by inflammation of the gallbladder. It is usually caused by the passage of a stone from the gallbladder into the cystic duct, which connects the gallbladder to the common bile duct. Cholecystitis causes painful enlargement of the gallbladder and is responsible for 10–25% of all gallbladder surgery.

Causes & symptoms

Gallstones are caused by an alteration in the chemical composition of bile, which is a fluid that helps the body break down and absorb fats. It is widely held that a diet high in fats and processed foods, and low in fiber and whole foods, is a strong contributor to gallstone formation. High levels of estrogen, insulin, or cholesterol can increase a person's risk of developing gallstones. If left untreated, the risk of developing anemia is also increased.

Gallbladder attacks usually follow a meal of rich foods, typically high in fat. The attacks often occur in the middle of the night, sometimes waking the patient with such intense pain that the episode ends in a visit to the emergency room. Pain often occurs on the right side of the body. The pain of a gallbladder attack begins in the abdomen and may radiate to the chest, back, or the area between the shoulders. Other symptoms of gallstones include inability to digest fats, low fever, chills and sweating, nausea and vomiting, indigestion, gas , belching, and clay-colored bowel movements.

Pregnancy or the use of birth control pills slow down gallbladder activity and increase the risk of gallstones,

as do diabetes, pancreatitis , and celiac disease . This is due to an individual's higher levels of cholesterol, insulin, or estrogen from oral contraceptives. Other factors that may encourage gallstone formation are:

• infection
• anemia
• obesity
• intestinal disorders
• coronary artery disease
• multiple pregnancies
• a high-fat, low-fiber diet
• smoking
• heavy drinking
• rapid weight loss

Diagnosis

When gallstones are suspected, blood tests for liver enzyme levels are often given. The levels are usually elevated when the stone cannot pass through the cystic duct or bile duct. Test results, taken together with symptom history (see above) and a physical exam, are simple and relatively inexpensive for diagnosing the presence of gallstones. However, ultrasound is the method of choice for a definite diagnosis. It has a high degree of accuracy, except in diagnosing cholecystitis (a stone in the cystic duct). Cholescintigraphy is an alternative method of diagnosis, in which radioactive dye is injected and photographed as it passes through the biliary system.

Treatment

An allergic reaction to certain foods may contribute to gallbladder attacks. These foods should be identified and removed from the diet, or at least seriously limited. Foods that might possibly bring on allergic reactions include eggs, pork, onions, chicken, milk, coffee, citrus, corn, nuts, and beans.

Other dietary changes may help relieve the symptoms of gallstones. Generally, a vegetarian diet is protective against the formation of gallstones. Recurrent attacks can be diminished by maintaining a healthy weight and a healthy diet.

Choleretic herbs encourage the liver to secrete bile. They help maintain the appropriate chemical composition of bile so that it does not form stones. These herbs include:

• A tincture of dandelion (Taraxacum officinale ), 2–6 ml once daily.
• Milk thistle seeds (Sylibum marianum ), a dose equivalent to 70–210 mg of silymarin.
• Artichoke leaves (Cynara scolymus ), 150 mg three times per day.
• Turmeric (Curcuma longa ), used as a spice; 150 mg three times per day.

Use of the above herbs cause some possible reactions, such as gas, diarrhea , nausea, and indigestion.

Other therapeutic approaches that have been found to be helpful in treating gallstones include homeopathy , traditional Chinese herbal medicine, and acupuncture . Knowledgeable practitioners should be consulted.

Allopathic treatment

Watchful waiting

One-third of all patients with gallstones never experience a second attack. For this reason, many doctors advise an attitude of "wait and see" after the first episode. Changing the diet or following a sensible weight loss plan may be the only treatments required. A person having only occasional mild gallstone attacks may be able to manage them by using non-prescription forms of acetaminophen, such as Tylenol or Anacin. A doctor should be notified if pain intensifies or lasts for more than three hours; if the fever rises above 101°F (38.3°C); or if the skin or whites of the eyes have a yellowish cast.

Surgery

Surgical removal of the gallbladder, called cholecystectomy, is the most common conventional treatment for recurrent or worsening gallstone attacks. However, surgery is unecessary in most cases where the gallstones remain without symptoms. Laparoscopic cholecystectomy is the technique most widely used. It has mostly replaced traditional open surgery because of a shorter recovery time, decreased pain, and reduced scarring. However, the open surgery procedure is still used in about 5% of cases because of various complications.

Nonsurgical therapy

If surgery is considered inappropriate, gallstones can be dissolved in 30–40% of patients by taking bile acids in tablet form. Dissolution of gallstones by this method may take many months or years depending on the size. Unfortunately, though, recurrence of stones is common after cessation of the medication.

Lithotripsy uses high-frequency sound waves directed through the skin to break up the stones. The process can be combined with the use of bile acid tablets. However, lithotripsy requires special equipment and is not always readily available.

Direct cholangiography can be used to remove gallstones by contact dissolution. The procedure is used to insert a catheter to inject medication into the gallbladder. Stones are often dissolved within a few hours by this method.

Expected results

Forty percent of all patients with gallstones have "silent gallstones" that do not require treatment. If symptoms develop, however, medical intervention may become necessary. Gallstone problems requiring treatment may also develop infections that require antibiotics. In rare instances, severe inflammation can cause the gall-bladder to burst, causing a potentially fatal situation. The gallbladder is not an organ that is required to retain health. It can be successfully removed, with no recurrence of stones. Fat digestion, however, becomes more difficult after surgery, since the gallbladder is no longer there to store and release bile as needed.

Prevention

It is easier, in general, to prevent gallstones than to reverse the process. The best way to prevent gallstones is to minimize risk factors. Since gallstones seem to develop more often in people who are obese, eating a balanced diet, exercising, and losing weight may help keep gallstones from forming. In addition, a diet high in dietary fiber and low in fats, especially saturated fats, is recommended. Processed foods should be replaced by complex carbohydrates, such as whole grains.

Increased intake of fluids will dilute the bile and inhibit gallstone formation. Six to eight glasses of water should be consumed daily, along with plenty of herbal teas and diluted juices.

Recent studies indicate that consumption of about two tablespoons of olive oil per day, which can be mixed with food, helps reduce cholesterol levels in the bloodstream and the gallbladder. However, large amounts of olive oil, taken as a so-called liver flush, should be avoided. This method can stress the gallbladder and lead to an emergency situation.

Resources

BOOKS

The Editors of Time-Life Books. The Medical Advisor: The Complete Guide to Alternative and Conventional Treatments. Alexandria, VA: Time-Life, Inc., 1996.

Gottlieb, Bill, ed. New Choices in Natural Healing. Emmaus, PA: Rodale Press, Inc., 1995.

Murray, Michael, N.D., and Joseph Pizzorno. Encyclopedia of Natural Medicine. Rocklin, CA: Prima Publishing, 1991.

Shaw, Michael, ed. Everything You Need to Know About Diseases. Springhouse, PA: Springhouse Corporation, 1995.

PERIODICALS

"Exercise Prevents Gallstone Disease." Journal Watch

ORGANIZATIONS

National Digestive Diseases Clearinghouse (NDDIC). 2 Information Way, Bethesda, MD 20892-3570.http://www.niddk.nih.gov/health/digest/nddic.htm.

National Institute of Diabetes and Digestive and Kidney Disorders of the National Institutes of Health. Bethesda, MD 20892. http://www.niddk.nih/gov/.

OTHER

Gallbladder Problems. http://www.sleh.com/fact-d04-gall.html.

http://www.thriveonline.com/health/Library/illsymp/illness229.html.

WebMD/Lycos. "How Are Gallstones and Gallbladder Disease Diagnosed?" http://webmd.lycos.com/content/dmk/dmk_article_3961803.

Patience Paradox

Gallstones

Definition

A gallstone is a solid crystal deposit that forms in the gallbladder, which is a pear-shaped organ that stores bile salts until they are needed to help digest fatty foods. Gallstones can migrate to other parts of the digestive tract and cause severe pain with life-threatening complications.

Description

Gallstones vary in size and chemical structure. A gallstone may be as tiny as a grain of sand or as large as a golf ball. Eighty percent of gallstones are composed of cholesterol. They are formed when the liver produces more cholesterol than digestive juices can liquefy. The remaining 20% of gallstones are composed of calcium and an orange-yellow waste product called bilirubin. Bilirubin gives urine its characteristic color and sometimes causes jaundice.

Gallstones are the most common of all gallbladder problems. They are responsible for 90% of gallbladder and bile duct disease, and are the fifth most common reason for hospitalization of adults in the United States. Gallstones usually develop in adults between the ages of 20 and 50; about 20% of patients with gallstones are over 40. The risk of developing gallstones increases with age-at least 20% of people over 60 have a single large stone or as many as several thousand smaller ones. The gender ratio of gallstone patients changes with age. Young women are between two and six times more likely to develop gallstones than men in the same age group. In patients over 50, the condition affects men and women with equal frequency. Native Americans develop gallstones more often than any other segment of the population; Mexican-Americans have the second-highest incidence of this disease.

Definitions

Gallstones can cause several different disorders. Cholelithiasis is defined as the presence of gallstones within the gallbladder itself. Choledocholithiasis is the presence of gallstones within the common bile duct that leads into the first portion of the small intestine (the duodenum). The stones in the duct may have been formed inside it or carried there from the gallbladder. These gallstones prevent bile from flowing into the duodenum. Ten percent of patients with gallstones have choledocholithiasis, which is sometimes called common-duct stones. Patients who don't develop infection usually recover completely from this disorder.

Cholecystitis is a disorder marked by inflammation of the gallbladder. It is usually caused by the passage of a stone from the gallbladder into the cystic duct, which is a tube that connects the gallbladder to the common bile duct. In 5-10% of cases, however, cholecystitis develops in the absence of gallstones. This form of the disorder is called acalculous cholecystitis. Cholecystitis causes painful enlargement of the gallbladder and is responsible for 10-25% of all gallbladder surgery. Chronic cholecystitis is most common in the elderly. The acute form is most likely to occur in middle-aged adults.

Cholesterolosis or cholesterol polyps is characterized by deposits of cholesterol crystals in the lining of the gallbladder. This condition may be caused by high levels of cholesterol or inadequate quantities of bile salts, and is usually treated by surgery.

Gallstone ileus, which results from a gallstone's blocking the entrance to the large intestine, is most common in elderly people. Surgery usually cures this condition.

Narrowing (stricture) of the common bile duct develops in as many as 5% of patients whose gallbladders have been surgically removed. This condition is characterized by inability to digest fatty foods and by abdominal pain, which sometimes occurs in spasms. Patients with stricture of the common bile duct are likely to recover after appropriate surgical treatment.

Causes and symptoms

Gallstones are caused by an alteration in the chemical composition of bile. Bile is a digestive fluid that helps the body absorb fat. Gallstones tend to run in families. In addition, high levels of estrogen, insulin, or cholesterol can increase a person's risk of developing them.

Pregnancy or the use of birth control pills can slow down gallbladder activity and increase the risk of gallstones. So can diabetes, pancreatitis, and celiac disease. Other factors influencing gallstone formation are:

• infection
• obesity
• intestinal disorders
• coronary artery disease or other recent illness
• multiple pregnancies
• a high-fat, low-fiber diet
• smoking
• heavy drinking
• rapid weight loss

Gallbladder attacks usually follow a meal of rich, high-fat foods. The attacks often occur in the middle of the night, sometimes waking the patient with intense pain that ends in a visit to the emergency room. The pain of a gallbladder attack begins in the abdomen and may radiate to the chest, back, or the area between the shoulders. Other symptoms of gallstones include:

• inability to digest fatty foods
• low-grade fever
• chills and sweating
• nausea and vomiting
• indigestion
• gas
• belching.
• clay-colored bowel movements

Diagnosis

Gallstones may be diagnosed by a family doctor, a specialist in digestive problems (a gastroenterologist), or a specialist in internal medicine. The doctor will first examine the patient's skin for signs of jaundice and feel (palpate) the abdomen for soreness or swelling. After the basic physical examination, the doctor will order blood counts or blood chemistry tests to detect evidence of bile duct obstruction and to rule out other illnesses that cause fever and pain, including stomach ulcers, appendicitis, and heart attacks.

More sophisticated procedures used to diagnose gallstones include:

• Ultrasound imaging. Ultrasound has an accuracy rate of 96%.
• Cholecystography (cholecystogram, gallbladder series, gallbladder x ray). This type of study shows how the gallbladder contracts after the patient has eaten a high-fat meal.
• Fluoroscopy. This imaging technique allows the doctor to distinguish between jaundice caused by pancreatic cancer and jaundice caused by gallbladder or bile duct disorders.

• Endoscopy (ERCP). ERCP uses a special dye to outline the pancreatic and common bile ducts and locate the position of the gallstones.
• Radioisotopic scan. This technique reveals blockage of the cystic duct.

Treatment

Watchful waiting

One-third of all patients with gallstones never experience a second attack. For this reason many doctors advise watchful waiting after the first episode. Reducing the amount of fat in the diet or following a sensible plan of gradual weight loss may be the only treatments required for occasional mild attacks. A patient diagnosed with gallstones may be able to manage more troublesome episodes by:

• applying heat to the affected area
• resting and taking occasional sips of water
• using non-prescription forms of acetaminophen (Tylenol or Anacin-3)

A doctor should be notified if pain intensifies or lasts for more than three hours; if the patient's fever rises above 101 °F (38.3 °C); or if the skin or whites of the eyes turn yellow.

Surgery

Surgical removal of the gallbladder (cholecystectomy ) is the most common conventional treatment for recurrent attacks. Laparoscopic surgery, the technique most widely used, is a safe, effective procedure that involves less pain and a shorter recovery period than traditional open surgery. In this technique, the doctor makes a small cut (incision) in the patient's abdomen and removes the gallbladder through a long tube called a laparoscope.

Nonsurgical approaches

LITHOTRIPSY. Shock wave therapy (lithotripsy ) uses high-frequency sound waves to break up the gallstones. The patient can then take bile salts to dissolve the fragments. Bile salt tablets are sometimes prescribed without lithotripsy to dissolve stones composed of cholesterol by raising the level of bile acids in the gallbladder. This approach requires long-term treatment, since it may take months or years for this method to dissolve a sizeable stone.

CONTACT DISSOLUTION. Contact dissolution can destroy gallstones in a matter of hours. This minimally invasive procedure involves using a tube (catheter) inserted into the abdomen to inject medication directly into the gallbladder.

Alternative treatment

Alternative therapies, like non-surgical treatments, may provide temporary relief of gallstone symptoms. Alternative approaches to the symptoms of gallbladder disorders include homeopathy, Chinese traditional herbal medicine, and acupuncture. Dietary changes may also help relieve the symptoms of gallstones. Since gallstones seem to develop more often in people who are obese, eating a balanced diet, exercising, and losing weight may help keep gallstones from forming.

Prognosis

Forty percent of all patients with gallstones have "silent gallstones" that produce no symptoms. Silent stones, discovered only when their presence is indicated by tests performed to diagnose other symptoms, do not require treatment.

Gallstone problems that require treatment can be surgically corrected. Although most patients recover, some develop infections that must be treated with antibiotics.

In rare instances, severe inflammation can cause the gallbladder to burst. The resulting infection can be fatal.

Prevention

The best way to prevent gallstones is to minimize risk factors. In addition, a 1998 study suggests that vigorous exercise may lower a man's risk of developing gallstones by as much as 28%. The researchers have not yet determined whether physical activity benefits women to the same extent.

KEY TERMS

Acalculous cholecystitis— Inflammation of the gallbladder that occurs without the presence of gallstones.

Bilirubin— A reddish-yellow waste product produced by the liver that colors urine and is involved in the formation of some gallstones.

Celiac disease— Inability to digest wheat protein (gluten), which causes weight loss, lack of energy, and pale, foul-smelling stools.

Cholecystectomy— Surgical removal of the gallbladder.

Cholecystitis— Inflammation of the gallbladder.

Choledocholithiasis— The presence of gallstones within the common bile duct.

Cholelithiasis— The presence of gallstones within the gallbladder.

Cholesterolosis— Cholesterol crystals or deposits in the lining of the gallbladder.

Common bile duct— The passage through which bile travels from the cystic duct to the small intestine.

Gallstone ileus— Obstruction of the large intestine caused by a gallstone that has blocked the intestinal opening.

Lithotripsy— A nonsurgical technique for removing gallstones by breaking them apart with high-frequency sound waves.

Resources

ORGANIZATIONS

National Digestive Diseases Clearinghouse (NDDIC). 2 Information Way.

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Building 31, Room 9A04, 31 Center Drive, MSC 2560, Bethesda, MD 208792-2560. (301) 496-3583. 〈http://www.niddk.nih.gov〉.

Gallstone Removal

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

Also known as cholelithotomy, gallstone removal is a procedure that rids the gallbladder of calculus buildup.

Purpose

The gallbladder is not a vital organ. It is located on the right side of the abdomen underneath the liver. The gallbladder’s function is to store bile, concentrate it, and release it during digestion. Bile is supposed to retain all of its chemicals in solution, but commonly one of them crystallizes and forms sandy or gravel-like particles, finally collecting into gallstones. The formation of gallstones causes gallbladder disease (cholelithiasis).

Chemicals in bile will form crystals as the gallbladder draws water out of the bile. The solubility of these chemicals is based on the concentration of three chemicals: bile acids, phospholipids, and cholesterol. If the chemicals are out of balance, one or the other will not remain in solution. Dietary fat and cholesterol are also implicated in crystal formation.

As the bile crystals aggregate to form stones, they move about, eventually blocking the outlet and preventing the gallbladder from emptying. This blockage results in irritation, inflammation, and sometimes infection (cholecystitis) of the gallbladder. The pattern is usually one of intermittent obstruction due to stones moving in and out of the way. Meanwhile, the gallbladder becomes more and more scarred. Sometimes, infection fills the gallbladder with pus, which is a serious complication.

Occasionally, a gallstone will travel down the cystic duct into the common bile duct and get stuck there. This blockage will back bile up into the liver as well as the gallbladder. If the stone sticks at the ampulla of Vater (a narrowing in the duct leading to the pancreas), the pancreas will also be blocked and will develop pancreatitis.

Gallstones will cause a sudden onset of pain in the upper abdomen. Pain will last for 30 minutes to several hours. Pain may move to the right shoulder blade. Nausea with or without vomiting may accompany the pain.

Demographics

Gallstones are approximately two times more common in females than in males. Overweight women in their middle years constitute the vast majority of patients with gallstones in every racial or ethnic group. An estimated 10% of the general population has gallstones. The prevalence for women between ages 20 and 55 is about 20%, and is higher after age 50 (25–30%). Women between the ages of 20 and 60 years are three times more likely to have gallstones than are men. Certain people, in particular the Pima tribe of Native Americans in Arizona, have a genetic predisposition to forming gallstones. Scandinavians also have a higher than average incidence of this disease.

There seems to be a strong genetic correlation with gallstone disease, because stones are more than four times as likely to occur among first-degree relatives. Since gallstones rarely dissolve spontaneously, the prevalence increases with age. Obesity is a well-known risk factor since being overweight causes chemical abnormalities that lead to increased levels of cholesterol. Gallstones are also associated with rapid weight loss secondary to dieting. Pregnancy is a risk factor since increased estrogen levels result in an increased

cholesterol secretion and abnormal changes in bile. However, while an increase in dietary cholesterol is not a risk factor, an increase in triglycerides is positively associated with a higher incidence of gallstones. Diabetes mellitus is also believed to be a risk factor for gallstone development.

Description

Surgery to remove the entire gallbladder with all its stones is usually the best treatment, provided the patient is able to tolerate the procedure. A relatively new technique of removing the gallbladder using a laparoscope has resulted in quicker recovery and much smaller surgical incisions than the 6-in (15-cm) gash under the ribs on the right that had previously been the standard procedure; however, not everyone is a candidate for this approach. If the procedure is not expected to have complications, laparoscopic cholecystectomy is performed. Laparoscopic surgery requires a space in the surgical area for visualization and instrument manipulation. The laparoscope with attached video camera is inserted. Several other instruments are inserted through the abdomen to assist the surgeon to maneuver around other nearby organs during surgery. The surgeon must take precautions not to accidentally harm anatomical structures in the liver. Once the cystic artery has been divided and the gallbladder dissected from the liver, the gallbladder can be removed.

If the gallbladder is extremely diseased (inflamed, infected, or has large gallstones), the abdominal approach (open cholecystectomy) is recommended. This surgery is usually performed with an incision in the upper midline of the abdomen or on the right side of the abdomen below the rib (right subcostal incision).

If a stone is lodged in the bile ducts, additional surgery must be done to remove it. After surgery, the surgeon will ordinarily insert a drain to collect bile

KEY TERMS

Bilirubin— A pigment released from red blood cells.

Cholecystectomy— Surgical removal of the gallbladder.

Cholelithotomy— Surgical incision into the gallbladder to remove stones.

Contrast agent— A substance that causes shadows on x rays (or other images of the body).

Cystic artery— An artery that brings oxygenated blood to the gallbladder.

Endoscope— An instrument designed to enter body cavities.

Jaundice— A yellow discoloration of the skin and eyes due to excess bile that is not removed by the liver.

Laparoscopy— Surgery performed through small incisions with pencil-sized instruments.

Triglycerides— Chemicals made up mostly of fat that can form deposits in tissues and cause health risks or disease.

until the system is healed. The drain can also be used to inject contrast material and take x rays during or aftersurgery.

A procedure called endoscopic retrograde cholan-giopancreatoscopy (ERCP) allows the removal of some bile duct stones through the mouth, throat, esophagus, stomach, duodenum, and biliary system without the need for surgical incisions. ERCP can also be used to inject contrast agents into the biliary system, providing finely detailed pictures.

Patients with symptomatic cholelithiasis can be treated with certain medications, a technique called oral bile acid litholysis or oral dissolution therapy. This technique is especially effective for dissolving small cholesterol-composed gallstones. Current research indicates that the success rate for oral dissolution treatment is 70-80% with floating stones (those predominantly composed of cholesterol). Approximately 10-20% of patients who receive medication-induced litholysis can have a recurrence within the first two or three years after treatment completion.

Extracorporeal shock wave lithotripsy is a treatment in which shock waves are generated in water by lithotripters (devices that produce the waves). There are several types of lithotripters available for gallbladder removal. One specific lithotripter involves the use of piezoelectric crystals, which allow the shock waves to be accurately focused on a small area to disrupt a stone. This procedure does not generally require analgesia (or anesthesia). Damage to the gallbladder and associated structures (such as the cystic duct) must be present for stone removal after the shock waves break up the stone. Typically, repeated shock wave treatments are necessary to completely remove gallstones. The success rate of the fragmentation of the gallstone and urinary clearance is inversely proportional to stone size and number: patients with a small solitary stone have the best outcome, with high rates of stone clearance (95% are cleared within 12–18 months), while patients with multiple stones are at risk for poor clearance rates. Complications of shock wave lithotripsy include inflammation of the pancreas (pancreatitis) and acute cholecystitis. Gallstones do recur after lithotripsy; the rate of recurrence after the first year is 6–7%, and after five years the rate of recurrence is 31–44%.

A method called contact dissolution of gallstone removal involves direct entry (via a percutaneous transhepatic catheter) of a chemical solvent (such as methyl tertbutylether, MTBE). MTBE is rapidly removed unchanged from the body via the respiratory system (exhaled air). Side effects in persons receiving contact dissolution therapy include foul-smelling breath, dyspnea (difficulty breathing), vomiting, and drowsiness. Treatment with MTBE can be successful in treating cholesterol gallstones regardless of the number and size of stones. Studies indicate that the success rate for dissolution is well over 95% in persons who receive direct chemical infusions that can last 5– 12 hours.

Diagnosis/Preparation

Diagnostically, gallstone disease, which can lead to gallbladder removal, is divided into four diseases: biliary colic, acute cholecystitis, choledocholithiasis, and cholangitis. Biliary colic is usually caused by intermittent cystic duct obstruction by a stone (without any inflammation), causing a severe, poorly localized, and intensifying pain on the upper right side of the abdomen. These painful attacks can persist from days to months in patients with biliary colic.

Persons affected with acute cholecystitis caused by an impacted stone in the cystic duct also suffer from gallbladder infection in approximately 50% of cases. These people have moderately severe pain in the upper right portion of the abdomen that lasts longer than six hours. Pain with acute cholecystitis can also extend to the shoulder or back. Since there may be infection inside the gallbladder, the patient may also have fever. On the right side of the abdomen below the last rib, there is usually tenderness with inspiratory (breathing in) arrest (Murphy’s sign). In about 33% of cases of acute cholecystitis, the gallbladder may be felt in the abdomen with palpation (feeling for tenderness). Mild jaundice can be present in about 20% of cases.

Persons with choledocholithiasis, or intermittent obstruction of the common bile duct, often do not have symptoms; but, if present they are indistinguishable from the symptoms of biliary colic.

A more severe form of gallstone disease is cholangitis, which causes stone impaction in the common bile duct. In about 70% of cases, these patients present with Charcot’s triad (pain, jaundice, and fever). Patients with cholangitis may have chills, mild pain, lethargy, and delirium, which indicate that infection has spread to the bloodstream (bacteremia). The majority of patients with cholangitis will have fever (95%), tenderness in the upper right side of the abdomen, and jaundice (80%).

In addition to a physical examination, preparation for laboratory (blood) and special tests is essential to gallstone diagnosis. Patients with biliary colic may have elevated bilirubin and should have an ultrasound study to visualize the gallbladder and associated structures. An increase in the white blood cell count (leu- kocytosis) can be expected for both acute cholecystitis and cholangitis (seen in 80% of cases). Ultrasound testing is recommended for acute cholecystitis patients, whereas ERCP is the test usually indicated to assist in a definitive diagnosis for both choledocholithiasis and cholangitis. Patients with either biliary colic or choledocholithiasis are treated with elective laparoscopic cholecystectomy. Open cholecystectomy is recommended for acute cholecystitis. For cholangitis, emergency ERCP is indicated for stone removal. ERCP therapy can remove stones produced by gallbladder disease.

Aftercare

Without a gallbladder, stones rarely recur. Patients who have continued symptoms after their gallbladder is removed may need an ERCP to detect residual stones or damage to the bile ducts caused by the original stones. Occasionally, the ampulla of Vater is too tight for bile to flow through and causes symptoms until it is opened up.

Risks

The most common medical treatment for gallstones is the surgical removal of the gallbladder

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

The procedure is performed in a hospital by a physician who specializes in general surgery and has extensive experience in the surgical techniques required.

(cholecystectomy). Risks associated with gallbladder removal are low, but include damage to the bile ducts, residual gallstones in the bile ducts, or injury to the surrounding organs. With open cholecystectomy, bile duct damage occurs at a rate of 1 per 1,000 patients; for laparoscopic cholecystectomy, the bile duct damage rate is 1–5 per 1,000 patients.

Normal results

Most patients undergoing laparoscopic cholecystectomy may go home the same day of surgery, and may immediately return to normal activities and a normal diet, while most patients who undergo open cholecystectomy must remain in the hospital for five to seven days. After one week, they may resume a normal diet, and in four to six weeks they can expect to return to normal activities.

Morbidity and mortality rates

Cholecystectomy is generally a safe procedure, with an overall mortality rate of 0–1 per 1,000. Infections occur in less than 1 per 1,000 patients undergoing laparoscopic cholecystectomy. Heart problems during the procedures occur at a rate of 5 per 1,000 for arrythmias and 1 per 1,000 for actual heart attack. Pregnant women who must undergo cholecystectomy have a high rate of fetal loss: 40 per 1,000 when no pancreatitis is present and as high as 600 per 1,000 when pancreatitis is present. The improved technique of laparoscopic cholecystectomy accounts for 90% of all cholecystectomies performed in the United States; the improved technique reduces time missed away from work, patient hospitalization, and postoperative pain.

Alternatives

There are no other acceptable alternatives for gallstone removal besides surgery, shock wave fragmentation, or chemical dissolution.

QUESTIONS TO ASK THE DOCTOR

• How long must I remain in the hospital following gallstone removal?
• How do I care for the my incision site?
• How soon can I return to normal activities following gallstone removal?

Resources

BOOKS

Feldman, M, et al. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 8th ed. St. Louis: Mosby, 2005.

Khatri, V. P., and J. A. Asensio. Operative Surgery Manual,1st ed. Philadelphia: Saunders, 2003.

Townsend, C. M., et al. Sabiston Textbook of Surgery, 17th ed. Philadelphia: Saunders, 2004.

Laith Farid Gulli, MD

Nicole Mallory, MS, PA-C

J. Polsdorfer, MD

Constance Clyde

Rosalyn Carson-DeWitt, MD

Gallstone removal

Definition

Also known as cholelithotomy, gallstone removal is a procedure that rids the gallbladder of calculus buildup.

Purpose

The gallbladder is not a vital organ. It is located on the right side of the abdomen underneath the liver. The gallbladder's function is to store bile, concentrate it, and release it during digestion. Bile is supposed to retain all of its chemicals in solution, but commonly one of them crystallizes and forms sandy or gravel-like particles, and finally gallstones. The formation of gallstones causes gallbladder disease (cholelithiasis).

Chemicals in bile will form crystals as the gallbladder draws water out of the bile. The solubility of these chemicals is based on the concentration of three chemicals: bile acids, phospholipids, and cholesterol. If the chemicals are out of balance, one or the other will not remain in solution. Dietary fat and cholesterol are also implicated in crystal formation.

As the bile crystals aggregate to form stones, they move about, eventually occluding the outlet and preventing the gallbladder from emptying. This blockage results in irritation, inflammation, and sometimes infection (cholecystitis) of the gallbladder. The pattern is usually one of intermittent obstruction due to stones moving in and out of the way. Meanwhile, the gallbladder becomes more and more scarred. Sometimes infection fills the gallbladder with pus, which is a serious complication.

Occasionally, a gallstone will travel down the cystic duct into the common bile duct and get stuck there. This blockage will back bile up into the liver as well as the gallbladder. If the stone sticks at the ampulla of Vater (a narrowing in the duct leading to the pancreas), the pancreas will also be blocked and will develop pancreatitis.

Gallstones will cause a sudden onset of pain in the upper abdomen. Pain will last for 30 minutes to several hours. Pain may move to the right shoulder blade. Nausea with or without vomiting may accompany the pain.

Demographics

Gallstones are approximately two times more common in females than in males. Overweight women in their middle years constitute the vast majority of patients with gallstones in every racial or ethnic group. An estimated 10% of the general population has gallstones. The prevalence for women between ages 20 and 55 varies from 5–20%, and is higher after age 50 (25–30%). The prevalence for males is approximately half that for women in a given age group. Certain people, in particular the Pima tribe of Native Americans in Arizona, have a genetic predisposition to forming gallstones. Scandinavians also have a higher than average incidence of this disease.

There seems to be a strong genetic correlation with gallstone disease, since stones are more than four times as likely to occur among first-degree relatives. Since gallstones rarely dissolve spontaneously, the prevalence increases with age. Obesity is a well-known risk factor since overweight causes chemical abnormalities that lead to increased levels of cholesterol. Gallstones are also associated with rapid weight loss secondary to dieting. Pregnancy is a risk factor since increased estrogen levels result in an increased cholesterol secretion and abnormal changes in bile. However, while an increase in dietary cholesterol is not a risk factor, an increase in triglycerides is positively associated with a higher incidence of gallstones. Diabetes mellitus is also believed to be a risk factor for gallstone development.

Description

Surgery to remove the entire gallbladder with all its stones is usually the best treatment, provided the patient is able to tolerate the procedure. A relatively new technique of removing the gallbladder using a laparoscope has resulted in quicker recovery and much smaller surgical incisions than the 6-in (15-cm) gash under the right ribs that had previously been the standard procedure; however, not everyone is a candidate for this approach. If the procedure is not expected to have complications, laparoscopic cholecystectomy is performed. Laparoscopic surgery requires a space in the surgical area for visualization and instrument manipulation. The laparoscope with attached video camera is inserted. Several other instruments are inserted through the abdomen (into the surgical field) to assist the surgeon to maneuver around the nearby organs during surgery. The surgeon must take precautions not to accidentally harm anatomical structures in the liver. Once the cystic artery has been divided and the gallbladder dissected from the liver, the gallbladder can be removed.

If the gallbladder is extremely diseased (inflamed, infected, or has large gallstones), the abdominal approach (open cholecystectomy) is recommended. This surgery is usually performed with an incision in the upper midline of the abdomen or on the right side of the abdomen below the rib (right subcostal incision).

If a stone is lodged in the bile ducts, additional surgery must be done to remove it. After surgery, the surgeon will ordinarily insert a drain to collect bile until the system is healed. The drain can also be used to inject contrast material and take x rays during or after surgery.

A procedure called endoscopic retrograde cholangiopancreatoscopy (ERCP) allows the removal of some bile duct stones through the mouth, throat, esophagus, stomach, duodenum, and biliary system without the need for surgical incisions. ERCP can also be used to inject contrast agents into the biliary system, providing finely detailed pictures.

Patients with symptomatic cholelithiasis can be treated with certain medications called oral bile acid litholysis or oral dissolution therapy. This technique is especially effective for dissolving small cholesterol-composed gallstones. Current research indicates that the success rate for oral dissolution treatment is 70–80% with floating stones (those predominantly composed of cholesterol). Approximately 10–20% of patients who receive medication-induced litholysis can have a recurrence within the first two or three years after treatment completion.

Extracorporeal shock wave lithotripsy is a treatment in which shock waves are generated in water by lithotripters (devices that produce the waves). There are several types of lithotripters available for gallbladder removal. One specific lithotripter involves the use of piezoelectric crystals, which allow the shock waves to be accurately focused on a small area to disrupt a stone. This procedure does not generally require analgesia (or anesthesia). Damage to the gallbladder and associated structures (such as the cystic duct) must be present for stone removal after the shock waves break up the stone. Typically, repeated shock wave treatments are necessary to completely remove gallstones. The success rate of the fragmentation of the gallstone and urinary clearance is inversely proportional to stone size and number: patients with a small solitary stone have the best outcome, with high rates of stone clearance (95% are cleared within 12–18 months), while patients with multiple stones are at risk for poor clearance rates. Complications of shock wave lithotripsy include inflammation of the pancreas (pancreatitis) and acute cholecystitis.

A method called contact dissolution of gallstone removal involves direct entry (via a percutaneous transhepatic catheter) of a chemical solvent (such as methyl tertiary-butyl ether, MTBE). MTBE is rapidly removed unchanged from the body via the respiratory system (exhaled air). Side effects in persons receiving contact dissolution therapy include foul-smelling breath, dyspnea (difficulty breathing), vomiting, and drowsiness. Treatment with MTBE can be successful in treating cholesterol gallstones regardless of the number and size of stones. Studies indicate that the success rate for dissolution is well over 95% in persons who receive direct chemical infusions that can last five to 12 hours.

Diagnosis/Preparation

Diagnostically, gallstone disease, which can lead to gallbladder removal, is divided into four diseases: biliary colic, acute cholecystitis, choledocholithiasis, and cholangitis. Biliary colic is usually caused by intermittent cystic duct obstruction by a stone (without any inflammation), causing a severe, poorly localized, and intensifying pain on the upper right side of the abdomen. These painful attacks can persist from days to months in patients with biliary colic.

Persons affected with acute cholecystitis caused by an impacted stone in the cystic duct also suffer from gallbladder infection in approximately 50% of cases. These people have moderately severe pain in the upper right portion of the abdomen that lasts longer than six hours. Pain with acute cholecystitis can also extend to the shoulder or back. Since there may be infection inside the gallbladder, the patient may also have fever. On the right side of the abdomen below the last rib, there is usually tenderness with inspiratory (breathing in) arrest (Murphy's sign). In about 33% of cases of acute cholecystitis, the gallbladder may be felt with palpation (clinician feeling abdomen for tenderness). Mild jaundice can be present in about 20% of cases.

Persons with choledocholithiasis, or intermittent obstruction of the common bile duct, often do not have symptoms; but if present, they are indistinguishable from the symptoms of biliary colic.

A more severe form of gallstone disease is cholangitis, which causes stone impaction in the common bile duct. In about 70% of cases, these patients present with Charcot's triad (pain, jaundice, and fever). Patients with cholangitis may have chills, mild pain, lethargy, and delirium, which indicate that infection has spread to the bloodstream (bacteremia). The majority of patients with cholangitis will have fever (95%), tenderness in the upper right side of the abdomen, and jaundice (80%).

In addition to a physical examination , preparation for laboratory (blood) and special tests is essential to gallstone diagnosis. Patients with biliary colic may have elevated bilirubin and should have an ultrasound study to visualize the gallbladder and associated structures. An increase in the white blood cell count (leukocytosis) can be expected for both acute cholecystitis and cholangitis (seen in 80% of cases). Ultrasound testing is recommended for acute cholecystitis patients, whereas ERCP is the test usually indicated to assist in a definitive diagnosis for both choledocholithiasis and cholangitis. Patients with either biliary colic or choledocholithiasis are treated with elective laparoscopic cholecystectomy. Open cholecystectomy is recommended for acute cholecystitis. For cholangitis, emergency ERCP is indicated for stone removal. ERCP therapy can remove stones produced by gallbladder disease.

Aftercare

Without a gallbladder, stones rarely recur. Patients who have continued symptoms after their gallbladder is removed may need an ERCP to detect residual stones or damage to the bile ducts caused by the original stones. Occasionally, the ampulla of Vater is too tight for bile to flow through and causes symptoms until it is opened up.

Risks

The most common medical treatment for gallstones is the surgical removal of the gallbladder (cholecsytectomy). Risks associated with gallbladder removal are low, but include damage to the bile ducts, residual gallstones in the bile ducts, or injury to the surrounding organs. With laparoscopic cholecystectomy, the bile duct damage rate is approximately 0.5%.

Normal results

Most patients undergoing laparoscopic cholecystectomy may go home the same day of surgery, and may immediately return to normal activities and a normal diet, while most patients who undergo open cholecystectomy must remain in the hospital for five to seven days. After one week, they may resume a normal diet, and in four to six weeks they can expect to return to normal activities.

Morbidity and mortality rates

Cholecystectomy is generally a safe procedure, with an overall mortality rate of 0.1–0.3%. The operative mortality rates for open cholecystectomy in males is 0.11% for males aged 30, and 13.84% for males aged 81–90 years. Women seem to tolerate the procedure better than males since mortality rates in females are approximately half those in men for all age groups. The improved technique of laparoscopic cholecystectomy accounts for 90% of all cholecystectomies performed in the United States; the improved technique reduces time missed away from work, patient hospitalization, and postoperative pain.

Alternatives

There are no other acceptable alternatives for gallstone removal besides surgery, shock wave fragmentation, or chemical dissolution.

See also Cholecystectomy.

Resources

books

bennett, j. claude, and fred plum, eds. cecil textbook of medicine. philadelphia: w. b. saunders co., 1996.

bilhartz, lyman e., and jay d. horton. "gallstone disease and its complications." in sleisenger & fordtran's gastrointestinal and liver disease, edited by mark feldman, et al. philadelphia: w. b. saunders co., 1998.

fauci, anthony s., et al., editors. harrison's principles of internal medicine. new york: mcgraw-hill, 1997.

feldman, mark, editor. sleisenger & fordtran's gastrointestinal and liver disease, 7th edition. st. louis: elsevier science, 2002.

hoffmann, alan f. "bile secretion and the enterohepatic circulation of bile acids." in sleisenger & fordtran's gastrointestinal and liver disease, edited by mark feldman, et al. philadelphia: w. b. saunders co., 1998.

mulvihill, sean j. "surgical management of gallstone disease and postoperative complications." in sleisenger & fordtran's gastrointestinal and liver disease, edited by mark feldman, et al. philadelphia: w. b. saunders co., 1997.

noble, john. textbook of primary care medicine, 3rd edition. st. louis. mosby, inc., 2001.

paumgartner, gustav. "non-surgical management of gallstone disease." in sleisenger & fordtran's gastrointestinal and liver disease, edited by mark feldman, et al. philadelphia: w. b. saunders co., 1998.

sabiston textbook of surgery, 16th edition. philadelphia: w. b. saunders co., 2001.

Laith Farid Gulli, MD
Nicole Mallory, MS, PA-C
J. Polsdorfer, MD

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

The procedure is performed in a hospital by a physician who specializes in general surgery and has extensive experience in the surgical techniques required.

QUESTIONS TO ASK THE DOCTOR

• How long must I remain in the hospital following gallstone removal?
• How do I care for the my incision site?
• How soon can I return to normal activities following gallstone removal?

Gallstones

Definition

Description

Demographics

Causes and symptoms

Diagnosis

Treatment

Nutrition/Dietetic concerns

Prognosis

Prevention

Resources

Definition

Gallstones are solid material that forms in the gallbladder or bile ducts. They are made of cholesterol, bilirubin, and calcium and range in size from a grain of sand to a golf ball. A single stone may be present, or they may exist in large numbers. Gallstones are also called choleliths.

Description

The gallbladder is a sac-like organ that lies on the right side of the abdomen underneath the liver. The liver makes bile that is then stored in the gallbladder. Bile is a yellowish-green fluid that helps digest fats and dissolve cholesterol. It contains bile salts, fats, proteins, cholesterol, and bilirubin. When a person eats a meal containing fat, the gallbladder contracts, and bile flows along the common bile duct, past the pancreatic duct that leads to the pancreas, and into the upper part of the small intestine (the duodenum) where it helps break down fat.

Gallstones form when some of the material in bile solidifies. At first the solid particles are small and may form a semi-solid sludge in the gallbladder. Gradually particles come together to form larger solid masses. As many as 20% of Americans have gallstones, and most do not know it. These are called asymptomatic gallstones, and they do not need treatment. Sometimes the stones are incidentally discovered during imaging tests (e.g. x rays, CT scan) being done for other purposes. Whether gallstones cause symptoms or not depends on their size and number and whether they move out of the gallbladder and block the common bile duct or the pancreatic duct.

Gallstones are categorized by their composition, not their shape or size. Cholesterol gallstones are the most common type of gallstone found in people in Western industrialized countries. In the United States, about 80% of gallstones are of this type. They are made of hardened cholesterol with small amounts of other substances. Pigment gallstones are black or dark brown stones made primarily of calcium and bilirubin. About 15-20% of gallstones are pigment stones. Primary bile duct stones are a third type of stone. These form directly in the bile duct instead of in the gallbladder and are rare.

Demographics

Whites, Mexican Americans, and Native American are more likely to develop gallstone disease than blacks or Asians. Women are two to three times more likely than men to develop gallstones. The lifetime risk of a woman developing gallstones is 50% but only 30% for a man. This difference is thought to be related to the effect of estrogen, a female hormone, on increasing the production of cholesterol.

Each year 1-3% of Americans develop symptoms of gallstone disease. Gallbladder surgery is the most commonly performed abdominal surgery in the United States. About half a million gallbladder operations are done each year. Gallstones are uncommon in children, and when present are usually related to disorders orders present at birth (congenital disorders).

Causes and symptoms

Researchers are not exactly sure why some people develop gallstones and others do not. One thought is that gallstones are more likely to develop when the gallbladder contracts infrequently or sluggishly and does not empty completely. Twin studies also suggest that heredity plays a moderate role in who develops gallstones.

What researches do know is that certain factors increase the risk of developing cholesterol gallstones. These include:

• overweight or obesity. The rate of gallstone formation increases with increasing weight. A body mass index.

(BMI) of 18.5–24.9 is considered normal weight and a BMI of 25.0–29.9 is overweight. A BMI of 30 and above is obese. A woman with a BMI of 32 has about a three times greater risk of developing gallstones than a woman with a BMI of 25.

• too much cholesterol. If the liver makes too much cholesterol, it may not stay dissolved in bile, but may crystallize out and form a solid. The amount of cholesterol in bile is not related to the amount of cholesterol in blood, and lowering-lowering drugs do not affect the amount of cholesterol the liver makes
• female gender, pregnancy, and estrogen drugs. The female hormone estrogen causes the liver to make more cholesterol. Women of reproductive age have higher levels of estrogen, which may explain why more women develop gallstones than men. In addition oral contraceptives (birth control pills) contain estrogen, and until recently, many women took drugs containing estrogen to combat hot flashes and other symptoms of menopause. Gallstone formation also increases during pregnancy, a time of increased estrogen levels.
• severe dieting. Losing weight rapidly—3 or more pounds a week— increases the likelihood of developing gallstones. About one-quarter of people who go on very low calorie diets (800 calories daily under medical supervision) and stay on them for several months develop gallstones. One-third of these people have symptoms severe enough to need gallbladder surgery. About one-third of people who have weight-loss surgery (bariatric surgery) also develop gallstones, usually in the first few months after surgery. Experts believe that somehow that triggers gallstone formation.

The chance of developing pigment gallstones is increased in individuals who have diseases such as sickle-cell anemia where there is an unusually high

KEY TERMS

Bile— a greenish-yellow digestive fluid produced by the liver and stored in the gallbladder. It is released into the small intestine where it helps digest fat, and then is removed from the body in feces.

Bilirubin— a yellowish pigment found in bile that is produced through the normal breakdown of red blood cells.

Cholesterol— a waxy substance made by the liver and also acquired through diet. High levels in the blood may increase the risk of cardiovascular disease.

Pancreas— a gland near the liver and stomach that secretes digestive fluid into the intestine and the hormone insulin into the bloodstream.

Perforation— a whole in the wall of an organ in the body.

rate of red blood cell turnover. Bilirubin is the main component of pigment gallstones, and these diseases increase amounts of bilirubin formed in the liver.

Many people with gallstones and never have any symptoms. Symptoms tend to occur when a gallstone moves out of the gallbladder and irritates or blocks the common bile duct or the entrance to the pancreatic duct. Sometimes symptoms come and go, as when stones irritating bile duct move into the much larger small intestine.

Symptoms can include the following:

• sudden pain in the upper right part of the abdomen that lasts anywhere from 15 minutes to several hours and does not go away with changes in position.
• pain radiating up into the back or right shoulder blade
• nausea and vomiting
• fever
• jaundice, a yellowing of the skin and whites of the eyes

Pain can occur frequently or at long intervals. Jaundice and fever are signs of advanced gallstone disease and infection. Sudden intense pain, especially if accompanied by high fever, nausea, vomiting, jaundice, and dark urine are signs of a medical emergency. Medical care should be sought immediately. Untreated bile duct blockages can lead to perforation of the bile duct, infection, and death.

Diagnosis

Diagnosis is made on the basis of a physical examination and imaging studies. Ultrasound is the least invasive and often the most effective way to locate gallstones. Other imaging studies, such as plain x rays and computed tomography (CT) scans, may also be used. These diagnostic tools may fail to located gallstones in the bile duct.

Other diagnostic tests can be used to better locate gallstones in the bile duct. A radionuclide scan, also called cholescintigraphy or HIDA scan, uses a small amount of radioactive tracer material that is injected into a vein. A machine locates the radioactive tracer as it moves through the body and in this way can tell if a stone is blocking the entrance or exit to the gallbladder or the common bile duct. Endoscopic retrograde chol-angiopancreatography (ERCP) is an endoscopic procedure use to locate, and sometimes remove, gallstones from the bile and pancreatic ducts. In this procedure, a thin tube called an endoscope is passed down the throat, through the stomach, and into the first part of the small intestine. Air and dye are then injected that allows the physician to see the place where the bile duct empties into the small intestine. If stones are present, a special tool may be inserted through the endoscope to remove them.

Treatment

By far, the most common and most successful treatment for gallstone disease is surgical removal of the gallbladder, an operation called a cholecystectomy. Removing the gallbladder has little effect on digestion. Bile simply goes directly from the liver to the small intestine instead of being stored. The difference is that the intestine receives a continuous flow of bile rather than receiving it only when it is needed. In about 1% of people, this continuous flow of bile causes mild diarrhea.

Most gallbladder surgery can be done laparos-copically. This means that surgery is done through a small cut in the abdomen instead of opening the entire abdominal cavity. A thin instrument called a laparo-scope that contains a miniature video camera and a light is inserted through the cut. The surgeon uses the image from the video camera to insert small instruments through the incision and remove the gallbladder. Recovery from laparoscopic gallbladder surgery often takes only a few days.

If the gallbladder or pancreas is infected, a serious complication, or if there is scarring from previous surgeries, open gallbladder surgery is necessary. This involves making a large incision in the abdomen.

Recovery time usually involves 5–7 days in the hospital and several weeks at home.

Some people are not healthy enough to undergo surgery. In this case, treatment options include a medication called ursodiol (Actigall) that helps dissolve cholesterol stones. However, the dissolving process can take 6ndash;18 months. Sometimes this drug is given to people going on medically supervised very-low-calorie diets for fast weight loss to help prevent them from developing gallstones. The other nonsurgi-cal treatment option is sound wave therapy (extracor-poreal shock wave lithotripsy). High-frequency sound waves are aimed at the gallstones to shatter them into smaller pieces. The pieces are then dissolved using the ursodiol. With nonsurgical treatment gallstones often reoccur. When the patient is healthy enough for surgery, gallbladder removal is usually the preferred option.

Nutrition/Dietetic concerns

Once recovery from surgery is complete, individuals who have had their gallbladder removed can return to a normal healthy diet.

Prognosis

Gallbladder surgery is quite safe, although all surgery carries risk of infection, reaction to anesthesia, and unintentional damage to other tissue. Once the gallbladder is removed, no more gallstones can form. Most complications from gallstones arise when treatment is delayed and the pancreas or gallbladder becomes infected. This is a serious, potentially fatal, complication because infection can spread rapidly and overwhelm the body. Gallstone disease is responsible for about 10,000 deaths in the United States each year, of which only a few hundred are caused by surgical complications. The vast majority are caused by gallstone disease that has caused infection.

Prevention

The formation of gallstones cannot be prevented. However maintaining a healthy weight, exercising regularly, and eating a diet high in whole grains and fresh fruit and vegetables and low in fat and cholesterol decrease the chance that gallstones will develop.

Resources

ORGANIZATIONS

American College of Gastroenterology. P.O. Box 342260

Bethesda, MD 20827-2260. Telephone: (301) 263-9000

Website: <http://www.acg.gi.org>

American Gastroenterological Association. 4930 Del Ray Avenue, Bethesda, MD 20814, Telephone: (301) 654-2089. Website: <:http://www.gastro.org>

Weight-control Information Network (WIN). 1 WIN Way, Bethesda, MD 20892-3665. Telephone: (877)946-4627 or (202) 828-1025. Fax: (202) 828-1028. Website: <http://win.niddk.nih.gov>.

OTHER

Faye, Maryanne L. and William K. Chiang. “Cholelithiasis.” eMedicine.com, June 12, 2006. <http://www.emedicine.com/emerg/topic97.htm>

Heuman, Douglas M. and Anastasios Mihas. “Cholelithiasis.” eMedicine.com, August 2, 2006. <http://www.emedicine.com/med/topic836.htm>

Mayo Clinic Staff. “Gallstones.” MayoClinic.com, July 25, 2005. <http://www.mayoclinic.com/healthgallstones/DS00165/>

Raboff, William K. “Gallstones.” eMedicineHealth.com, August 10, 2005. <http://www.emedicinehealth.com/gallstones/article_em.htm>

Weight-control Information Network (WIN). “Dieting and Gallstones.” National Institute of Diabetes and Digestive and Kidney Diseases, April 2006. <http://win.niddk.nih.gov/publications/gallstones.htm>

Tish Davidson, A.M.