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Dr. Minocha  is a practicing gastroenterologist and author of "Natural Stomach Care: Treating and Preventing Digestive Disorders with Best of Eastern and Western Therapies"


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Gallstones occur in 10-20% of the population. Just because you have certain symptoms of pain or indigestion does not mean that gallstones are the culprit. In fact, 80% of patients never have symptoms. Normally gallstones occur in the gallbladder; however 15% of patients also have them in the bile ducts connecting the gallbladder to the intestine.

What are gallstones?

Most stones are made up of cholesterol. About 15% of gallstones are pigment stones and comprised of pigments resulting from the breakdown of red blood cells. Majority of the gallstones cannot be seen on a plain x ray.

Who gets gallstones?

While they may occur in any person, some people are more likely than others to develop gallstones. Risk factors include native Americans, sedentary lifestyle, obesity, women especially those with multiple births, rapid weight loss and patients with diseased small intestine.

Clinical features

The most common problem encountered is biliary colic. It is sudden but steady pain occurring in the middle and right upper abdomen. It may or may not be related to meals and usually subsides in a few hours. No abnormalities are seen on physical exam or on laboratory tests. Abnormal lab tests suggest the presence of stones in the bile duct. Less than one-third of patients with an initial episode of biliary pain have a recurrence over the ensuing 2 years.

Cholecystitis is the inflammation of the gallbladder and may be acute or chronic. Acute inflammation causes prolonged severe right upper abdominal pain radiating to the shoulder or the back. Fever is usually present and lab tests suggest infection.

Chronic cholecystitis is the chronic inflammation of the gallbladder as a result of gallstones causing recurring episodes of biliary pain and/or mechanical irritation to the wall of gallbladder. There is poor correlation between the severity of chronic inflammation and the symptoms.

Since the bile duct and the pancreatic duct drain into the small intestine through the same opening, stones in the bile duct may block this exit door leading to "traffic jam" for both bile and pancreatic secretions. This may result in inflammation of pancreas known as pancreatitis.

Gas and bloating while frequently attributed to gallstones is not caused by them. Disorders causing symptoms similar to gallstones include kidney stones, pancreatitis, irritable bowel syndrome, ulcers, and heart attack.

 

Investigations

The most commonly used test is the ultrasound. It is a non-invasive test and can detect gallstones in most cases. However, bile duct stones may be missed. In addition, gallstones may be absent in 5% of cases with acute cholecystitis. A gallbladder (HIDA) scan using a radionuclide material can accurately diagnose acute cholecystitis in 95% of the cases.

Oral cholecystogram, an x ray of the gallbladder after ingestion of a radio-opaque material has comparable accuracy but is rarely used.

ERCP (endoscopic retrograde cholangiopancreatography) is just like an upper GI scope test, except that the equipment used is somewhat different. The scope is passed through the mouth and advanced into the small intestine to the opening of bile and pancreatic duct. A small catheter is then passed though the scope and into the duct where dye is injected. Ducts can then be visualized by x ray. Stones from the bile duct can be removed during this procedure.

Surgical treatment

Patients with problems due to gallstones require surgical removal of the gallbladder. Almost half a million such operations are performed each year in the US alone. A mini-surgery (laproscopic cholecystectomy) is the norm and results in tiny scars and early discharge from the hospital.

Some patient have symptoms suggestive of gallbladder disease but no gallstones can be identified on routine testing. Scans documenting ineffective emptying of gallbladder (less than 15%) suggest chronic gallbladder disease and these patients may benefit from a cholecystectomy.

In carefully selected patients, the Surgery is rewarding and results in total resolution of symptoms in up to 90% of the patients. A small percentage of patients develop bile-acid diarrhea because of the loss of storage capacity of gallbladder. In some patients all the symptoms prior to surgery persist. In such cases, gallbladder was probably not the cause of their problems in the first place.

Medical treatment

Medical treatment for gallstones is unsatisfactory and is used for patients unable to undergo surgery. It include ultrasound shock wave lithotripsy, and then taking pills (Actigall) to keep the bile from forming stones. Gallstones usually return when medication is stopped.

Asymptomatic gallstones

Just because you have gallstones does not mean that you should undergo surgery for removal of gallbladder in order to prevent future problems. Risk from complications related to the surgery for asymptomatic gallstones outweigh the benefits. The long-term risk for gallbladder cancer is less than one percent.

Best treatment for asymptomatic stones is no treatment. Exceptions include 1) patients at high risk for gallbladder cancer like young native American females, or presence of large gallbladder polyp, 2) young patients with sickle cell disease, 3) prolonged space travel or travel to remote areas and 4) patients awaiting organ transplantation.

 

 

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