Written by Mr Charles Imber; Consultant HPB Surgeon, Hadley Wood Hospital
As gallstones are so common (affecting up to 10% of people living in the Western world), it is a common reason for people to come to my clinic and see me for treatment . Despite a large amount of good information being available to patients there is also a lot of misinformation available on the internet that causes at best unnecessary worry and at worst the wrong treatment choices.
What are gallstones?
Gallstones are hard particles that develop in the gallbladder. which is a small, egg-shaped organ located in the upper right abdomen below the liver.
Is a particular size of stone more likely to cause complications?
Gallstones can range in size from a grain of sand to a golf ball, and it is possible to have different sizes together. They can cause sudden pain in the upper abdomen, classically located on the right side radiating through to the back, although also sometimes seen more centrally or in the right shoulder. This pain, called a gallbladder attack or biliary colic, occurs when gallstones block the ducts of the biliary tract.
Why me? – what have I done wrong to get stones, or should I blame my parents?
Imbalances in the substances that make up bile cause gallstones. Gallstones may form if bile contains too much cholesterol, too much bilirubin, or not enough bile salts. Scientists do not fully understand why these imbalances occur. Gallstones also may form if the gallbladder does not empty completely or often enough.
Certain people have a higher risk of developing gallstones than others:
- Gender: Women are more likely to develop gallstones than men – extra estrogen can increase cholesterol levels in bile and decrease gallbladder contractions, which may cause gallstones to form
- Age: People over age 40 are more likely to develop gallstones than younger people
- Family history: People with a family history of gallstones do have a higher risk
- Obesity: People who are obese, especially women, have increased risk of developing gallstones. Obesity increases the amount of cholesterol in bile, which can cause stone formation.
- Rapid weight loss: Rapid weight loss can prevent the gallbladder from emptying properly – low-calorie diets and bariatric (weight-loss) surgery lead to rapid weight loss and increased risk of gallstones
- Diet: Research suggests diets high in calories and refined carbohydrates and low in fibre increase the risk of gallstones
- Certain intestinal diseases: Diseases that affect normal absorption of nutrients, such as Crohn’s disease, are associated with gallstones
- Metabolic syndrome, diabetes, and insulin resistance: These conditions increase the risk of gallstones, metabolic syndrome also increases the risk of gallstone complications
What are the symptoms and complications of gallstones?
Many people with gallstones do not have symptoms.
If gallstones block the cystic duct, which connects the gall bladder to the main bile duct, pressure increases in the gallbladder, causing a gallbladder attack. The pain usually lasts from 1 to several hours. Gallbladder attacks often follow heavy meals, but can come with no precipitant.
Gallbladder attacks usually stop when gallstones move and no longer block the ducts. If the gallbladder is persistently obstructed then infection of the gallbladder (cholecystitis) can occur leading to more prolonged pain, and symptoms associated with infection like fever, nausea, reduced appetite etc.
Small stones can migrate out of the gallbladder into the bile duct leading to biliary obstruction and jaundice (yellow tinge in the white of the eyes, skin, dark urine and pale stools|). Even more serious are stones that lodge at the lower end of the bile duct, obstructing the duct draining form the pancreas, that can then lead a potentially very serious inflammation of the pancreas (pancreatitis).
When should a person seek medical advice about gallstones?
People who think they have had a gallbladder attack should notify their GP. Although these attacks usually resolve the GP can then refer the patient to a gallbladder specialist for discussion about treatment.
More worrying symptoms that require urgent medical advice include:
- abdominal pain lasting more than 5 hours
- nausea and vomiting
- fever—even a low-grade fever—or chills
- yellowish color of the skin or whites of the eyes, called jaundice
- tea-colored urine and light-colored stools
These symptoms may be signs of serious infection or obstruction of the gallbladder, liver, or pancreas.
How are gallstones diagnosed?
The GP will normally arrange for some blood tests that look at markers of inflammation (FBC), and also at the liver function (LFT) to check bile is draining normally. Then the diagnosis of gall stones can best be confirmed by ultrasound.
If either the liver function tests or the ultrasound suggest potential obstruction of the bile ducts at presentation because of migration of stones, then an MRI (MRCP) can be performed. This provides a road map that is useful to the surgeon, and usually if stones are visible within the biliary tree a special type of endoscopy known as an ERCP (endoscopic retrograde cholangiopancreatogram) will be performed before removal of the gallbladder to clear the ducts making subsequent surgery safer. Very rarely tiny stones cannot be well seen on ultrasound, but if symptoms persist an even more accurate form of ultrasound that is combined with endoscopy can be used called Endoscopic Ultrasound (EUS).
Gallstone symptoms may be similar to those of other conditions, such as appendicitis, ulcers, pancreatitis, and gastroesophageal reflux disease.
Sometimes, silent gallstones that haven’t caused any symptoms are found when a person does not have any symptoms often incidentally on an ultrasound performed for another reason.
How are gallstones treated?
If gallstones are not causing symptoms (silent) , treatment is usually not needed. It must be explained to patients that multiple small stones are at risk of migration and causing complications such as pancreatitis in the future, although this risk is hard to quantify. If the patient is young and fit they may wish to discuss with a specialist the pros and cons of cholecystectomy.
However if a person has had one gallbladder attack more episodes are likely to follow. The usual treatment in this situation is surgery to remove the gallbladder.
Surgery to remove the gallbladder, called cholecystectomy, is one of the most common operations performed on adults in the United Kingdom. The gallbladder is not an essential organ, which means a person can live normally without one. Once the gallbladder is removed, bile flows out of the liver through the hepatic and common bile ducts and directly into the duodenum, instead of being stored in the gallbladder.
In the vast majority of patients a laparoscopic cholecystectomy is the favored option. It involves the surgeon making several tiny incisions in the abdomen and inserting a laparoscope—a thin tube with a tiny video camera attached. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of organs and tissues. While watching the monitor, the surgeon uses instruments to carefully separate the gallbladder from the liver, bile ducts, and other structures. Then the surgeon removes the gallbladder through one of the small incisions. Patients usually receive general anaesthesia but the majority can be performed as a day case if the patient is fit and willing. They may feel a little bloated, and have some vague abdominal pain requiring simple analgesics for 2-3 days, but can be self-caring and fully mobile during this period.
If a patient has had a lot of complex upper abdominal surgery in the past, then it is possible that scar tissue will prevent a safe laparoscopic approach, and then an open operation through a small incision is required (open cholecystectomy). Most experienced surgeons may still look in laparoscopically first, but will convert to open surgery if unsafe to proceed. During an attack of acute cholecystitis where there is a lot of inflammatory tissue around the gall bladder and vital structures then the conversion rate to an open procedure is slightly higher. Timing of the operation in relation to the attack used to be limited to the first few days, or after several weeks, but again this is no longer the case in experienced hands. Conversion to an open procedure should never be looked upon as a failure by surgeon or patient, as often it will prevent a serious injury from occurring.
Though complications from gallbladder surgery are rare, the most common potentially serious is injury to the bile ducts. An injured common bile duct can leak bile and cause a painful and possibly dangerous infection, as well as having potential long term consequences for the patient. One or more additional operations may be needed to repair the bile ducts. These occur in less than 1 percent of cholecystectomies, and it is reasonable to ask your surgeon about their overall experience, conversion rates, and bile duct injury rates.
There is no good non-surgical treatment of gallstones. Oral dissolution therapy simply does not work, and lithotripsy can often exacerbate the risk of complication by shattering stones into small fragments, and is not recommended. If a patient is really not fit for surgery and has severe infection / abscess formation in the gallbladder than a drain can be inserted as a life saving measure without resorting to an operation.
Does having my gall bladder removed cause ongoing symptoms?
Post cholecystectomy syndrome has been described which is persistence of abdominal pain, bloating, or diarrhoea that continues at 3 months after surgery. It occurs in less than 15% of all patients and normally settles completely by 1 year, unless there are retained stones or complications of the operation.
Mr. Imber is currently a leading London Teaching Hospital Consultant as well as the Clinical Lead for Liver Transplantation at The Royal Free Hospital London. His areas of interest include General and HPB Surgery. He is also in charge of the National Organ Retrieval Service (NORS) for the North London region. He completed his medical degree at Cambridge University, where he also received an honours degree in Oncology and Immunology. Mr Imber is also a Fellow of the Royal College of Surgeons of England.
Mr Imber is available for consultations at Hadley Wood Hospital. Please call our enquiries team on +44 20 3930 2475 for further information.