Gallstones (Cholelithiasis): Symptoms, Causes & Treatment

Gallstones/Cholelithiasis are quite prevalent around the world and its incidence increases after 50 years of age. The prevalence is higher among women than men. Gallstones develop because of abnormal bile composition. Biliary sludge/Gallstone sludge acts as a presursor of gallstones. It is a thick mucous material and its presence denotes that there is imbalance between gallbladder mucin secretion and elimination and more specifically there is supersaturation of bile with either cholesterol or calcium bilirubinate. There are multiple reasons for development of biliary sludge like hypomotility( due to surgery , burns or pregnancy) or Oral contraceptives etc. 

Types of Gallstones

Cholesterol Gallstones

Cholesterol is a water insoluble compound and is absorbed with the formation of micelles which requires bile acids. If there is an excess of cholesterol as compared to bile acids , cholesterol vesicles start aggregating into multivesicles and precipitate as a stone.

Pigment Gallstones

Pigment stones are composed of mainly calcium bilirubinate and these are very common in patients having high unconjugated biirubin available for conjugation. The conditions like chronic hemolysis and Cirrhosis contributes to this. There is an enzyme called as Beta-Glucuronidase  which is produced by bacteria(among chronically infected individuals) deconjugates the bilirubin and precipitates the bilirubin as pigment stones.

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Gallstone Causes/Risk factors

Cholesterol Gallstones

• Demography- Greater prevalence in North Europe and North America than in Asia.
• Obesity
• Female sex 
• Rapid weight loss-  There is increased mobilization of tissue cholesterol that alleviates biliary cholesterol secretion but the enteroheaptic circualtion of bile acids is decreased.
• Impaired emptying of gallbladder due to progesterone in pregnancy.
• Increased age
• Clofibrate therapy
• High calorie diet

Pigment Gallstones

Demography- Asia( mainly rural settings due to high prevalence of parasitic infections)

• Chronic Hemolysis
• Cystic fibrosis
• Ileal diseases
• Alcoholic Liver Cirrhosis

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Gallstone Symptoms

• The most common presentation of Gallstone is colicky pain in right upper quadrant of the abdomen. 
• The pain generally radiates to the intrascapular area, right scapula and shoulder and it get worsen with fatty food.
• Nausea and vomiting
• If there are fever or chills then there are chances that patient might have developed 

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Gallstone Complications

• Cholecystitis
• Biliary colic
• Cholangitis
• Cholecystitis
• Gallstone ileus
• Fistula( Causing Bile Acid Diarrhea)
• Perforation
• Acute Pancreatitis
• Obstructive Jaundice

Gall Stone ILEUS

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Gallstone Diagnosis

• Right upper quadrant ultrasound is used to diagnose the gall bladder stones.
• HIDA scan can be used for accurate identification of cystic duct obstruction and can suspect acute cholecystitis. However it is contraindicated in pregnancy.

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Gallstone Treatment

• Prophylactic Cholecystectomy- It should be considered in the patients who has frequent symptoms that are interfering the daily routine of the patient or there is risk of impending infection. 
• Ursodeoxycolic acid can be used to dissolve the gallstones in the patients with <5mm of stones or if they are non-surgical candidates.

Side effects of Cholecystectomy/Gall bladder surgery

Fatty food intolerance, Nausea, vomiting,heartburn and postcholecystectomy diarrhea are few of the side effects of gall bladder surgery.

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Prevention of Gallstones

• Intake of high fibre and low saturated fatty acid diet
• Weight loss at moderate rate ( avoid quick weight loss)
• Exercise

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