Gallstone Disease

Gallstone disease, also known as cholelithiasis or choledocholithiasis, refers to the formation of stones within the gallbladder or bile ducts from precipitated bile components. These stones can lead to significant medical conditions, especially when they obstruct the biliary system.

Signs & Symptoms

Most people with gallstones are asymptomatic. However, symptomatic gallstones can cause intense cramp-like visceral pain in the right upper abdomen known as biliary colic or gallbladder attack. This pain is often accompanied by nausea and vomiting, and it may radiate to the tip of the scapula, known as "Collin's sign". Symptomatic gallstones can also cause fever, referred pain between the shoulder blades, and jaundice if bilirubin leaks into the bloodstream. Gallbladder attacks frequently occur after heavy meals, particularly in the evening or at night.

Other Complications

Complications from gallstones include cholecystitis (inflammation of the gallbladder), pancreatitis (inflammation of the pancreas), obstructive jaundice, cholangitis (infection of the bile ducts), and rarely, gallbladder cancer. Severe cases can lead to gallstone ileus, an obstruction caused by a gallstone eroding into the bowel.

Risk Factors

Factors increasing the risk of gallstones include female gender, age over 40, obesity, diabetes, rapid weight loss, pregnancy, and certain ethnicities such as Native Americans. Nutritional risk factors include a diet low in fibre, high in simple carbohydrates, and low in essential nutrients like folate, magnesium, and vitamin C. Prolonged use of proton pump inhibitors, certain medications (e.g., statins and fibrates), and conditions like Gilbert syndrome and celiac disease also increase the risk.

Pathophysiology and Composition

Gallstones form when bile contains excessive cholesterol and insufficient bile salts. They are classified based on their composition into cholesterol stones, pigment stones, and mixed stones.

• Cholesterol Stones: Light yellow to dark green or brown, and composed of at least 80% cholesterol by weight.
• Pigment Stones: Small, dark stones primarily composed of bilirubin and calcium salts.
• Mixed Stones: Contain 20-80% cholesterol along with calcium compounds, and arise secondary to biliary tract infections.

Images

Types of Gallstones

Gallbladder opened to show small cholesterol gallstones.

X-ray microtomograph of a gallstone.

The large, yellow stone is largely cholesterol, while the green-to-brown stones are mostly composed of bile pigments.

Diagnosis

Diagnosis is typically confirmed by abdominal ultrasound, which detects gallstones and associated complications. Other imaging techniques include ERCP and MRCP. Blood tests may reveal complications.

Images

A 1.9 cm gallstone impacted in the neck of the gallbladder and leading to cholecystitis as seen on ultrasound. There is 4 mm gall bladder wall thickening.

Biliary sludge and gallstones. There is borderline thickening of the gallbladder wall.

Treatment

Lithotripsy

Extracorporeal shock wave lithotripsy (ESWL) is a non-invasive method using high-energy sound waves to disintegrate gallstones. Side effects include biliary pancreatitis and liver haematoma.

Surgical

Cholecystectomy, or gallbladder removal, is the most effective treatment with a 99% success rate in eliminating recurrence. It can be performed via open surgery or laparoscopically. Laparoscopic cholecystectomy is preferred due to shorter recovery times.

Medical

Medications like ursodeoxycholic acid (UDCA) and chenodeoxycholic acid (CDCA) can dissolve small cholesterol stones. UDCA can also prevent gallstone formation during weight loss.

Images

Large gallstone.

Numerous small gallstones made up largely of cholesterol.

Use in Traditional Medicine

Gallstones, particularly from old dairy cows, are valued in traditional Chinese medicine as antipyretics and antidotes. These stones are termed calculus bovis or niu-huang.

Self-assessment MCQs (single best answer)

Which term is synonymous with gallstone disease?

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What is the primary symptom of symptomatic gallstones?

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Which of the following is NOT a risk factor for gallstone formation?

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Which imaging technique is commonly used to diagnose gallstones?

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What type of gallstone is primarily composed of bilirubin and calcium salts?

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What is the preferred surgical treatment for gallstone disease?

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Which symptom is associated with a gallbladder attack and may radiate to the tip of the scapula?

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Which medication can be used to dissolve small cholesterol stones?

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What is a potential complication of gallstones that involves inflammation of the pancreas?

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In traditional Chinese medicine, what are gallstones from old dairy cows used as?

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