According to the National Institute of Diabetes and Digestive and Kidney Diseases, (1) 10 to 15% of adults have gallstone disease in the United States.
About a million cases are diagnosed annually, and 800, 000 operations are performed to treat gallstones. These statistics make gallstone disease one of the most prevalent gastrointestinal disorders that require hospitalization.
In this article, we will be looking at gallstones, with scientific-based information on its diagnosis, management, and prevention.
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What are gallstones?
Gallstones are hardened deposits (stones) that form in the gallbladder. Gallstones can form as either one large deposit or many deposits at the same time. When it comes to size, they range from the size of a grain of sand to as large as a golf ball. (2)
The gallbladder is part of the biliary system, which also includes the liver and pancreas. It is a small hollow, pear-shaped organ where bile is stored and concentrated before it is released in the small intestines, where it digests fats and aids in the absorption of fat-soluble vitamins and other nutrients. The gallbladder is located on the upper right side of the abdomen, just below the liver. (3)
Basically, there are two types of gallstones (4):
- Cholesterol stones which account for more than 80% of gallstones and often appear as yellow-green. They are composed mainly of undissolved cholesterol.
- Pigment stones are smaller and darker. They form when there is excess bilirubin in bile juice.
Signs and symptoms of gallstones
Gallstones may or may not cause signs and symptoms. Actually, most people do not know that they have gallstones until they are detected when one is undergoing tests for other reasons. Most of the manifestations mentioned below are experienced when the gallstones lodge in the bile ducts and cause a blockage. (5)
- The most common symptom is sudden onset of pain in the right upper portion of the abdomen, just below the breastbone. The pain comes in episodes and can last anywhere from a few minutes to hours. The pain is usually severe, dull, constant and may radiate to the right shoulder or the region between the shoulder blades.
- Nausea and vomiting
- Digestive problems such as bloating, indigestion, and heartburn
- Intolerance to fatty foods
- Jaundice (yellowing of the skin and eyes) especially if bilirubin is high
Warning signs of a serious problem that requires immediate attention:
- Intense and persistent abdominal pain
- High fever with chills
Causes of gallstones
Gallstones occur when high levels of fat and bile form crystals. These crystals then combine and with time, expand to form stones.
Most studies (6) show that gallstones result when there is:
High cholesterol: In normal circumstances, bile has enough active compounds to dissolve cholesterol excreted by the liver. However, when the liver produces more cholesterol than the bile can handle, the excess cholesterol that is not dissolved crystalizes and then eventually collects up to form gallstones.
High bilirubin: Bilirubin is an orange-yellow pigment that is formed during the breakdown of red blood cells. The liver excretes bilirubin through the bile. When there is a liver problem such as liver cirrhosis or excessive breakdown of red blood cells like in sickle cell anemia, there will too much bilirubin which contributes to gallstones formation.
Impaired motility of the gallbladder: This means that the gallbladder is not emptying completely or often enough. Poor muscle tone as seen in individuals with spinal cord injury may contribute to this problem. Bile ends up becoming very concentrated, leading to crystallization then gallstone formation.
Specific factors predispose some individuals to gallstones more than others. (7) They are:
- Age 40 years and above
- Being overweight or obese
- Leading an inactive lifestyle
- High-fat and high-cholesterol diet
- Low fiber diet
- Family history of gallstones
- Having a liver disease
- Losing weight too fast such as in a crash or starvation diet
- Diabetes mellitus
- Certain medications such as birth control pills, hormone replacement therapy or cholesterol-lowering drugs
Women, the elderly, Native Americans, and Mexican-Americans are also at a higher risk.
How are gallstones diagnosed?
To diagnose gallstones, doctors rely on the combination of the presenting signs and symptoms, imaging studies and laboratory investigations. (8) Imaging studies enable visualization of the gallbladder while laboratory investigations help to detect abnormal biomarker levels or infections.
Abdominal ultrasound is the most commonly used because it is non-invasive and involves absolutely no exposure to radiation. It identifies gallstones and can show gallbladder or bile duct inflammation and blockage.
Oral cholecystogram (OCG) involves taking iodine orally for one or two consecutive nights. The iodine is then absorbed by the digestive tract into the bloodstream, is transported to the liver and then excreted to bile in the gallbladder. Because iodine is dense and radiopaque, it helps to visualize the gallbladder on the X-ray. The drawback of this test is that it takes a while and a diseased gallbladder may not be visualized.
An abdominal ultrasound and OCG are often enough to diagnose gallstones, but there are some cases that other methods may be useful. Additional tests include:
Endoscopic ultrasound assesses digestive and lung diseases. It involves insertion of a tube into the mouth down through the stomach up to the upper part of the small intestines. An endoscopic ultrasound is considered more superior to the traditional abdominal ultrasound as it provides high-resolution images of even very small lesions.
Magnetic resonance cholangiopancreatography (MRCP) uses a powerful magnetic field and radio waves to evaluate the liver, gallbladder, bile ducts, and the pancreas.
Cholescintigraphy (HIDA scan) is useful for telling whether the gallbladder is emptying properly or is there is obstruction by gallstones, tumors, or another underlying disease. It is done by injecting a harmless radioactive material into a person’s vein. A special gamma camera then tracks the movement of the material through the liver, gallbladder, bile duct and small intestines.
Endoscopic retrograde cholangiopancreatography (ERCP) combines both the upper gastrointestinal tract endoscopy and X-ray imaging to diagnose gallstones, bile and pancreatic problems. During the procedure, the doctor can open blocked or narrowed ducts, break or remove gallstones, get tissue for laboratory examination and remove tumors if there are any.
Chest X-ray is also necessary to rule out chest infections such as pneumonia as they may cause pain in the upper region of the abdomen.
Laboratory tests comprise blood tests to rule out infections or obstruction.
Urinalysis may also be done to rule out kidney infection.
Ways of Treating Gallstones
Gallstones that cause signs and symptoms may require surgery while others typically do not require invasive treatment. Treatment options include:
Cholecystectomy refers to a surgical procedure to remove the gallbladder. There are two different kinds of cholecystectomy operations. It can be done either laparoscopically or as an open surgical procedure. During an open cholecystectomy, the surgeon makes a cut just below the ribs on the right side, then reaches for the gallbladder and resects it.
Laparoscopic cholecystectomy, on the other hand, is less invasive as the surgeon makes several small incisions (one inch or less) then uses an instrument known as a laparoscope to visualize the gallbladder and remove it. Laparoscopic cholecystectomy requires a shorter hospital stay, has less pain and has a shorter recovery period.
Once the gallbladder is removed, bile flows directly from the liver to the small intestines. One can continue with a normal and productive life since this organ is not essential for survival. Also, no special change of diet is required after the gallbladder is gone. The only problem that may occur occasionally is mild diarrhea when bile flows to the intestines when it is not needed.
Extracorporeal shockwave lithotripsy (ESWL) although not commonly used, it can be considered when endoscopic or surgical removal of gallstones fail. The procedure uses a device that generates shock waves to break gallstones into tiny pieces that can pass through the biliary system without causing any breakages.
Medications to dissolve gallstones. Drugs commonly used include Chenodeoxycholic acid (chenodiol), Ursodeoxycholic acid (ursodiol) or both.
Chenodiol works by preventing the production of cholesterol in the liver and therapeutically dissolves cholesterol that makes the gallstones.
Ursodiol helps regulate cholesterol levels by reducing the rate at which the small intestines absorb cholesterol and also breaks up crystals containing cholesterol.
The main drawback with medications is that it may take months or even years to dissolve gallstones. Moreover, the gallstones can recur when medications are ceased. They are therefore reserved for only those people who are not in a state to undergo surgery.
Gallstones once formed, can either shrink, grow or remain the same size for years. Moreover, new ones can develop while the existing ones are dissolved or expelled out of the body. Therefore, there is a need for the gallstones to be removed surgically or be conservatively managed. When surgery is not an option or cannot be done right away, certain measures can be taken to relieve or prevent the symptoms.
Adequate water intake- Fluid intake should be in sufficient amounts at regular intervals throughout the day to dilute bile acids and decrease the stay time of bile in the gallbladder. It helps to reduce pain and prevent the formation of new gallstones.
Avoid fatty or greasy meals- Unsaturated fats mainly trigger gallstone pain. Therefore, skip high-fat foods and liquids like fries, sauces, gravies, or full-fat dairy and instead, go for minimally processed high-fiber foods.
Take pain medications- Gallbladder pain can be relieved using over the counter analgesics such as acetaminophen. However, the painkillers should be taken with the full knowledge of a doctor. Masking the pain without treating the underlying problem will only worsen the condition over time.
Apple cider vinegar- Raw apple cider vinegar has anti-inflammatory properties that can help relieve the pain. (9) The acidic nature also stops the liver from making excessive cholesterol. To prepare the drink, mix one tablespoon of raw, unfiltered apple cider vinegar in a glass of apple juice then take any time there is a painful episode.
Alternatively, one can add two teaspoons of apple cider vinegar and one teaspoon of lemon juice to a cup of warm water. The mixture can be taken on an empty stomach in the morning for a duration of 2 to 4 weeks.
It is important not to take apple cider vinegar directly as the acidic content can damage teeth. Preferably, use a drinking straw.
Milk thistle – Is best known for its liver protectant and decongestant properties. Milk thistle can be traced back to the famous English herbalist Nicolas Culpepper who described it as an excellent plant for carrying off bile. (10) It contains phytochemicals that act as antioxidants and demulcents of bile.
Milk thistle can be taken in supplement form, or the seeds can be ground into a powder then taken as a tea. To prepare milk thistle tea, grind one tablespoon of the seeds, put the powder in three cups of water and bring the water to boil. Let it steep for 20 minutes then add honey to taste. Take two to three times daily for a week.
Heat compressions – Application of heat on the right upper region of the abdomen can be soothing. It calms spasms caused by pain and relieves pressure by causing vasodilatation of blood vessels and relieving pressure from bile build up.
Gallbladder cleanse- Although there is no scientific backup for a gallbladder cleanse, some practitioners recommend it. It involves drinking or eating a combination of olive oil and lemon juice or apple juice and vegetable juice. The mixture is taken over the course of two or more days, without eating anything else.
A gallbladder cleanse is also referred to as a gallbladder flush or liver flush.
Complications of gallstones
As the gallstones mix with other contents of the gallbladder, they block inflow and outflow of digestive juices and enzymes.
If the blockage persists, the gallbladder is forced to contract harder and because of the increased pressure, swelling and stasis of bile juice, inflammation results.
An inflammation of the gallbladder is known as cholecystitis and is almost always present in people with gallstones. It is the commonest complication of gallstones.
The pancreas also often gets inflamed, what is known as pancreatitis. This inflammation especially if severe, can be life-threatening. Other infrequent complications are obstructive jaundice, cholangitis (an infection of the biliary tract), and cancer of the gallbladder. (11)
Can they be prevented?
Medications and surgery alone cannot fix the underlying problem of gallstone formation. It is thus best to understand how to prevent gallstones from forming or returning once again. Prevention of gallstones has all to do with adjusting the modifiable predisposing factors mentioned above.
1.Maintain a healthy weight
Being obese or overweight increases the likelihood of gallstones since the body tends to produce higher levels of cholesterol in the liver. (12)
Additionally, it contributes to inflammation and swelling of the gallbladder due to the fat surrounding the internal organs. The healthiest thing is therefore to maintain a healthy weight within the allowed setpoint of age and height.
2.Lose weight in a healthy way
If losing weight, use sustainable gradual methods that encourage exercise and a healthy balanced diet. Avoid crash or fad diets that restrict calorie intake on the extreme as they can trigger deficiencies, electrolyte imbalance and other factors that increase the chances of gallstone formation.
Also, weight cycling or losing weight then regaining it repeatedly increases the chances of developing gallstones. Therefore, aim to lose weight at a slower pace and keep it off for a long time. Aim to lose 0.5 to 1 kilogram per week. (13)
3.Eat a sensible diet
A high-fiber, low-fat, and low-cholesterol diet keeps bile cholesterol in liquid form and can dramatically support liver and gallbladder health.
A high fiber diet (vegetables, whole grains, beans and peas, fruits and cereals) protects against gallstones as it speeds up intestinal motility since slow emptying of the gallbladder contributes to increased cholesterol and saturation of bile, which are the key predisposing factors in gallstone formation. (14)
When it comes to fats, focus on healthy fats such as those from avocados, olive oil, fish, cheese, sprouted chia seeds, and nuts. They are easy to digest, reduce inflammation and help the bladder to contract and empty on a regular basis.
4.Take supplements that are approved by a qualified healthcare provider
Some supplements such as vitamin C, iron and soy lecithin (15) may help prevent gallstones while others are harmful to the liver and gallbladder.
Before taking any supplements, it is recommended to always consult a healthcare provider. Another critical thing to note is that supplements are not meal replacements. They should be integrated into a nutrient-rich diet and healthy lifestyle.
Regular exercise reduces the risk of not only gallbladder diseases (16) but so many other chronic illnesses. The American Heart Association (17) recommends 30 minutes of exercise 5 minutes a week to prevent excessive cholesterol buildup.