What Is Cholelithiasis? – Causes, Symptoms, Treatment

What Is Cholelithiasis? or gallstones are hardened deposits of digestive fluid that can form in your gallbladder. The gallbladder is a small organ located just beneath the liver. The gallbladder holds a digestive fluid known as bile that is released into your small intestine. In the United States, 6% of men and 9% of women have gallstones, most of which are asymptomatic. In patients with asymptomatic gallstones discovered incidentally, the likelihood of developing symptoms or complications is 1% to 2% per year. Asymptomatic gallbladder stones found in a normal gallbladder and normal biliary tree do not need treatment unless they develop symptoms.

Gallstones or cholelithiasis are responsible for one of the most prevalent digestive disorders in the United States. They are considered a disease of developed populations but are present around the world. It is both the result of a chronic disease process and the cause of subsequent acute disorders of the pancreatic, biliary, hepatic, and gastrointestinal tract.

Types of Gallstones

Depending on the etiology, gallstones have different compositions. The three most common types are

• Cholesterol gallstones
• Black pigment gallstones
• Brown pigment gallstones – Ninety percent of gallstones are cholesterol gallstones.
• Mixed stones –  Mixed (brown pigment stones) typically contain 20–80% cholesterol (or 30–70%, according to the Japanese- classification system). Other common constituents are calcium carbonate, palmitate phosphate, bilirubin, and other bile pigments (calcium bilirubin, calcium palmitate and calcium stearate). Because of their calcium content, they are often radiographically visible.

The two main kinds of gallstones are

• Cholesterol stones – These are usually yellow-green. They’re the most common, making up 80% of gallstones.
• Pigment stones – These are smaller and darker. They’re made of bilirubin.

Causes of Gallstones

There are three main pathways in the formation of gallstones

• Cholesterol supersaturation – Normally, bile can dissolve the amount of cholesterol excreted by the liver. But if the liver produces more cholesterol than bile can dissolve, the excess cholesterol may precipitate as crystals. Crystals are trapped in gallbladder mucus, producing gallbladder sludge. With time, the crystals may grow to form stones and occlude the ducts which ultimately produce the gallstone disease.
• Excess bilirubin – Bilirubin, a yellow pigment derived from the breakdown of red blood cells, is secreted into bile by liver cells. Certain hematologic conditions cause the liver to make too much bilirubin through the processing of breakdown of hemoglobin. This excess bilirubin may also cause gallstone formation.
• Gallbladder hypomotility or impaired contractility – If the gallbladder does not empty effectively, bile may become concentrated and form gallstones.
• There’s too much bilirubin in your bile – Conditions like cirrhosis, infections, and blood disorders can cause your liver to make too much bilirubin.
• Your gallbladder doesn’t empty all the way – This can make your bile very concentrated.
• There’s too much cholesterol in your bile – Your body needs bile for digestion. It usually dissolves cholesterol. But when it can’t do that, the extra cholesterol might form stones.
• Your gallbladder doesn’t empty correctly – If your gallbladder doesn’t empty completely or often enough, bile may become very concentrated, contributing to the formation of gallstones.

The following factors are known to increase the risk of gallstones

• Age – The risk of developing gallstones increases with age, especially after you reach the age of 40.
• Genes – If someone in your family has had gallstones.
• Sex – Women are more likely to get gallstones than men. The female sex hormone estrogen is believed to increase the risk of gallstones.
• Cirrhosis – A severe liver disease caused by metabolic disorders or excessive consumption of alcohol.
• Being very overweight.
• Losing a lot of weight in a short time – This happens a lot in very obese people who have surgery to make their stomach smaller.
• Functional problems of the gallbladder – The organ cannot contract (squeeze bile out) properly.
• Short bowel syndrome – A disorder that can develop after surgical removal of a large segment of the small bowel.
• Special high – calorie liquid food.
• Hemolysis – A disease that causes an increased breakdown of red blood cells.
• Pregnancy.
• Using the contraceptive pill or estrogen tablets during menopause (hormone therapy).
• Diabetes.

Symptoms of Cholelithiasis

Diagnosis of Cholelithiasis

Your doctor will do a physical exam and might order tests including

• Blood tests – These check for signs of infection or blockage and rule out other conditions.
• Ultrasound – This makes images of the inside of your body.
• Abdominal ultrasound – This test is the one most commonly used to look for signs of gallstones. Abdominal ultrasound involves moving a device (transducer) back and forth across your stomach area. The transducer sends signals to a computer, which creates images that show the structures in your abdomen.
• CT scan – Specialized X-rays let your doctor see inside your body, including your gallbladder.
• Magnetic resonance cholangiopancreatography (MRCP) – This test uses a magnetic field and pulses of radio wave energy to take pictures of the inside of your body, including your liver and gallbladder.
• Cholescintigraphy (HIDA scan) – This test can check whether your gallbladder squeezes correctly. Your doctor injects a harmless radioactive material that makes its way to the organ. A technician can then watch its movement.
• Endoscopic retrograde cholangiopancreatography (ERCP) – Your doctor runs a tube called an endoscope through your mouth down to your small intestine. They inject a dye so they can see your bile ducts on a camera in the endoscope. They can often take out any gallstones that have moved into the ducts.
• Endoscopic ultrasound (EUS) – This procedure can help identify smaller stones that may be missed on an abdominal ultrasound. During EUS your doctor passes a thin, flexible tube (endoscope) through your mouth and through your digestive tract. A small ultrasound device (transducer) in the tube produces sound waves that create a precise image of surrounding tissue.

Treatment of Cholelithiasis 

Non-Pharmacological

• Supportive therapy and dietary modifications –  elective cholecystectomy only for symptomatic patients who are surgical candidates or asymptomatic patients at risk of gallbladder cancer
• Supportive therapy – Fasting or dietary modification (decreased fat intake)

Medication

• Spasmolytics – (e.g., dicyclomine)
• Analgesia – NSAIDs, opioids
• Cholesterol gallstones – can sometimes be dissolved with ursodeoxycholic acid taken by mouth, but it may be necessary for the person to take this medication for years.^[rx]
• Gallstones may recur, however, once the drug is stopped. Obstruction of the common bile duct with gallstones can sometimes be relieved by endoscopic retrograde sphincterotomy (ERS) following endoscopic retrograde cholangiopancreatography (ERCP).^[rx]

Surgical

• Cholecystectomy (gallbladder removal) has a 99% chance of eliminating the recurrence of cholelithiasis. The lack of a gallbladder may have no negative consequences in many people. However, there is a portion of the population—between 10 and 15%—who develop a condition called postcholecystectomy syndrome^[rx] which may cause nausea, indigestion, diarrhea, and episodes of abdominal pain.^[rx]

There are two surgical options for cholecystectomy

• Open cholecystectomy is performed via an abdominal incision (laparotomy) below the lower right ribs. Recovery typically requires 3–5 days of hospitalization, with a return to normal diet a week after release and to normal activity several weeks after release.^[rx]
• Laparoscopic cholecystectomy, introduced in the 1980s, is performed via three to four small puncture holes for a camera and instruments. Post-operative care typically includes a same-day release or a one-night hospital stay, followed by a few days of home rest and pain medication.^[rx]
• Laparoscopic cholecystectomy (removal of the gallbladder through multiple small incisions; this is less invasive and a more commonly used technique)
• Lithotripsy (the technique that uses electric shock waves to dissolve gallstones; it is not commonly used today)
• Open cholecystectomy (removal of the gallbladder through a single, large incision; this is a more invasive and less commonly used technique)

Complications

Complications of gallstones may include:

• Inflammation of the gallbladder – A gallstone that becomes lodged in the neck of the gallbladder can cause inflammation of the gallbladder (cholecystitis). Cholecystitis can cause severe pain and fever.
• Blockage of the common bile duct – Gallstones can block the tubes (ducts) through which bile flows from your gallbladder or liver to your small intestine. Severe pain, jaundice, and bile duct infection can result.
• Blockage of the pancreatic duct – The pancreatic duct is a tube that runs from the pancreas and connects to the common bile duct just before entering the duodenum. Pancreatic juices, which aid in digestion, flow through the pancreatic duct. A gallstone can cause a blockage in the pancreatic duct, which can lead to inflammation of the pancreas (pancreatitis). Pancreatitis causes intense, constant abdominal pain and usually requires hospitalization.
• Gallbladder cancer – People with a history of gallstones have an increased risk of gallbladder cancer. But gallbladder cancer is very rare, so even though the risk of cancer is elevated, the likelihood of gallbladder cancer is still very small.

References

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