Gall Stones - the stones in the biliary tree!

Online Physician By Online Physician, 1st Oct 2011 | Follow this author | RSS Feed
Posted in Wikinut>Health>General Health>Diseases & Infections

Gallstones are an important cause of severe abdominal pain requiring emergency surgery and causing death. The types of gall stones, their formation, clinical features, investigations, treatment and prevention are discussed here.

What are these "Gall Stones"?

Bile is a fluid essential for the digestion of food, particularly the lipids (fatty food). This is formed in the liver, stored in the gall-bladder and released with the entry of food in to the small intestine. The pathway the bile is formed, stored and transported is known as the hepato-biliary tree. Stones can form in this pathway, giving rise to a variety of complaints and might even become a threat to the life (causing as much as 1-2% of all deaths in certain countries) if not treated promptly. The disease of formation of stones in the biliary tree is known as gall stone disease or cholelithiasis.

How common are they?

Gall stones are quite common all over the world, and are seen in 10-20% of dead bodies during post-mortem examinations. It is known to account for a major bulk of routine surgeries and 11% of emergency surgeries in general surgical units. The disease is 4 times commoner among women compared to men and is seen to be increasing in numbers over the past few years, emphasizing the importance of being aware of the disease and how to prevent the disease.

What are the types of gallstones?

Gall stones can be made up of:
· Cholesterol – forming as much as 70% of the gall stones
· Phospholipids (with a compound called lecithin contributing for the most part)
· Bile salts (cholic acid, chenodeoxycholic acid, deoxycholic acid and lithocholic acid)
· Bile pigment (sodium torocholate and sodium glycholate)

How are they formed?

The gall stones, like the stones in the urinary tract, are formed due to sluggish flow of bile. This causes increased concentration of cholesterol leading to deposition of cholesterol as stones. Infections and foreign material or a previously formed stone itself can act as a nidus (a foundation) for a stone to build-up. Once formed, the stones increase in size with further deposition of the substances stated above.

What are the Risk Factors?

Risk factors for the development of the disease can be classified into:
1. Geographical factors
2. Factors of the patient which are non-modifiable (which cannot be changed)
3. Diseases of the patient
4. Drug and surgery related (iatrogenic)

1. Geographical Factors
The disease is seen to occur in higher proportions in particular regions of the world (e.g. – Lower part of the North American continent). Variations of the occurrence are also seen within continents and countries, showing the influence of diet on the disease. The number of cases is rising rapidly in the Europe with the high consumption of food rich in cholesterol.

2. Non-modifiable Factors
The family history is an important risk factor in gall stone disease. It had been observed that the risk of developing gall stones of a person with a family member of gall stone disease has twice the risk of a normal person. The disease is also seen to increase with age and is 4 times commoner among females.

3. Diseases of the Patient
Obesity and diabetes (diabetes mellitus) places the patients at a higher risk of developing gall stones. Inflammatory bowel diseases (e.g. – Crohn’s disease, Ulcerative colitis) the circulation of bile salts is altered and therefore can be complicated by gall stone disease. Diseases associated with destruction of red cells inside the circulation i.e. haemolytic anaemias (e.g. – thalassaemia, sickle cell anaemia, autoimmune anaemias) increases the formation of pigment stones.

4. Drug and Surgery Related
Oral contraceptive pills are one of the commonest drugs promoting the formation of gall stones. In addition, treating the patients for a long term with intravenous nutrition can precipitate the disease. Surgical removal of the stomach to prevent and reduce obesity, surgery for acid reflux and removal of part of the small bowel are all associated with an increased risk.

In summary it is said that, the fat, fair, fertile females in their forties and fifties are said to be at a higher risk of forming gall stones.

What are the features of gallstone disease?

Gall stones are usually silent. However, when they can give rise to symptoms while in the gall bladder as well as when they come out of gall bladder and get stuck in the biliary tree. In the gall bladder, they can give rise to severe pain, known as the biliary colic. The pain occurs in the upper abdomen, particularly towards the right side and is of sudden onset, lasting from 20 minutes to as long as several hours. It may also radiate (perceived as moving) from the upper abdomen in front to the back.

The stones may obstruct the flow of bile from the liver and can give rise to yellowish discolouration of the skin and eyes. This is almost always associated with passage of very dark coloured urine and pale yellowish stools. The stones can also be complicated by infections of the gall bladder and the biliary tree as they can act as a focus where bacteria can attach to and multiply. These infections can give rise to the perforation and leakage of bile and can be life-threatening. Infections of the bile ducts (known as cholangitis) are associated with high grade fever, with chills and rigors in addition to the pain and yellowish discolouration. The gall stones can also block the drainage of the pancreas (which has a common outflow tract into the intestine with the pancreas) and can give rise to pancreatitis (a disease of the pancreas which can be life-threatening if not treated promptly).

How are the gallstones investigated?

The most convenient investigation to detect gall stones is the ultra-sound scan which detects majority of the stones as well as the complications associated with it. MR cholangiography (magnetic resonance cholangography) is the best investigation to visualize the biliary tree and detect stones. A special tube like endoscope with a light and a camera known as Endoscopic Retrograde Cholangio Pancreatography-scope (ERCPscope) can be inserted via the mouth to reach the opening of the biliary tree to observe the area for stones. This has the advantage of having tools such as a diathermy knife and a special basket to extract the stones so that the stones lying close by can be removed. In addition, a dye can be injected into the biliary tree to visualize the area with an X-ray film taken soon after. This may also have an ultrasound device, so that the biliary tree can be scanned from inside rather than outside.

"When and How" are the gallstones treated?

Gall stones are not usually treated unless they become symptomatic (i.e. cause pain, yellowish discolouration or infection). However, gall stones are removed in those who cannot take the risk of developing severe pain or any complications (e.g. – aircraft pilots) or those who may not be able to reach a surgical facility urgently (e.g. – minors, research scientists in North pole). The mainstay of treatment is surgery – which may be emergency surgery if the life of the patient is at risk (particularly with the involvement of the gall bladder – cholecystitis) or delayed surgery once the patient is settled down. The stones and the gall bladder may also be removed with laparoscopic surgery. ERCP-scope can be used to remove stones as described above with a good success rate.

How to Prevent Gallstone Disease!!

The most important aspect of the disease is how to prevent the formation of gall stones. As in any other disease, simple life-style modifications can decrease the risk markedly. The main aim in prevention should be to reduce weight. The disease could be prevented by,
1. Increasing physical activity (e.g. – brisk walking for at least 30 minutes per day in 3-4 days per week)
2. Reducing intake of food rich in fat, sugar and starch (e.g. – snacks such as potatoes chips)
3. Reducing the time spent in front of the TV and computer
4. Decrease the intake of cholesterol rich food – almost all meats, egg yolk, butter fruit
5. Control diabetes – reduce intake of sugar, take the drugs in correct doses

If there is any suspicion of the gall stone disease, going by the features described above, it is always wise to consult the primary health care provider (e.g. – GP) before the disease becomes complicated. Awareness of the disease can reduce the need for emergency surgery and prolonged hospitals stay.

moderator Mark Gordon Brown moderated this page.
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author avatar Denise O
7th Feb 2012 (#)

A really good, informative piece about gall stones.
Thank you for sharing.:)

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author avatar Tranquilpen
21st Feb 2012 (#)

This is very informative and easy to digest. Thank you for sharing.

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