Gallbladder is a small vesicle placed under the liver in the right upper quadrant of the abdomen. Its main function is to store and thicken bile that flows in from the liver through the bile duct system. The bile flowing in from the liver contains a relatively high percentage of water; in the gallbladder it is thickened. The water from the bile passes into the mucosal cells and is drained away. Under normal circumstances, adult gallbladder contains about 50 ml of bile. Gallstones may arise in the gallbladder from various reasons.
Incidence of Gallstones
The presence of gallstones in the gallbladder is professionally called cholecystolithiasis. The term choledocholithiasis indicates on the other hand gallstones in the bile ducts. Both these conditions can be in summary called cholelithiasis. Gallstones are counted among the most common gastrointestinal diseases. It occurs in up to 30% of the population, more often in women. The increase in the incidence of cholelithiasis in recent years has been associated with the deteriorating lifestyle, especially unhealthy eating habits. Despite the fact that in 60-80% patients this disease remains asymptomatic, there still are many patients in which the disease is symptomatic due to its high prevalence.
Symptoms of Gallstones
Gallstones may present with feelings of fullness in the stomach area, feeling of pressure right under the ribs, fatty food intolerance, nausea and flatulence. A typical symptom of this disease is biliary colic. It occurs when one of the gallstones gets stuck in the neck of the gallbladder; this makes the bile passage impossible. The gallbladder muscles clench harder in order to push the bile out of the gallbladder and this causes severe pain that comes in waves. In place of impaction substances causing inflammation are released. Biliary colic occurs most often in the evening; it is located in the right hypochondrium and the pain often shoots to the back or shoulder blade. The patient is restless, pale, feverish, and in time can become slightly yellowed. In more than half of the cases, pain and vomiting are present; however the vomiting does not bring relief. A biliary colic is often caused by fatty foods ingestion, at times it can also be provoked by physical exertion or cold. The main risk factors for development of gallstones are higher age, obesity, female gender, ethnicity, and multiple pregnancies in anamnesis.
Classification of Gallstones
Gallstones can be divided into several groups according to their composition. In developed countries, the most common type of gallstones are cholesterol gallstones. These develop due to increased amount of cholesterol in the bile, due to disorders of motility of the gallbladder, or from other causes. In this type of gallstones, there is typically only one large stone present in the gallbladder.
The other type, pigment gallstones, is divided into the brown pigment gallstones (usually develop due to biliary tract infections) and black pigment gallstones (resulting from conditions accompanied by overproduction of bile pigment called bilirubin). Pigment gallstones are generally smaller than cholesterol gallstones, so that they can easier get into the bile duct system and cause choledocholithiasis. Usually, there are more pigment gallstones present in the gallbladder.
Sometimes, mixed gallstones can occur – these combine features of both previous types.
Complications of Gallstones
Gallstones should be treated as soon as they are diagnosed because the complication rate is quite high. The complications can be either early, or late.
Early complications of gallstones include acute inflammation of the gallbladder, which manifests by pain in the right hypochondrium, nausea, vomiting, and sometimes elevated body temperature. Another early complication is hydrops of the gallbladder. It is a consequence of choledocholithiasis; the gallbladder is enlarged due to obstruction of the bile duct system. As a result, a pathologic communication between the gallbladder and the intestine may arise.
Late complications of gallstones include chronic cholecystitis and development of malignant tumour in the gallbladder.
Diagnosis of Gallstones
Diagnosis of gallstones is based on a detailed history, focused on typical symptoms of the patient. To confirm the diagnosis, ultrasound is used. The ultrasound is able to visualize the gallstones and to evaluate the gallbladder wall function. The gallbladder wall is usually clearly wider than normal due to concurrent inflammation. If a more detailed view is necessary, CT scan can be used. It is a painless examination that uses several X-rays to display the examined area.
Treatment of Gallstones
Removal of the gallbladder is usually recommended when gallstones are present. This operation is nowadays performed mainly laparoscopically. In this technique, only a few small holes are used to enter the abdominal cavity, which significantly reduced the risk of the operation. Non-surgical treatment for gallstones, especially dietary measures, is recommended only for short period after a biliary colic before the surgery is performed.