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Gallstones: description, causes, symptoms

by Josephine Andrews
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Gallstones are crystallized components of the bile. They can develop in the gallbladder or bile duct, favored by factors such as obesity and being female. Gallstones usually do not cause any symptoms. Depending on their position and size, however, they can also cause pain – from moderate discomfort in the upper right abdomen to severe biliary colic. Read more about signs of gallstones, treatment, diet tips and prognosis here!

ICD codes for this disease:

ICD codes are internationally valid codes for medical diagnoses. They can be found, for example, in doctor’s letters or on certificates of incapacity for work.

K80

quick overview

  • What are gallstones? Crystalized components of the bile in the form of tiny stones (gravel) or larger stones. Depending on the location, a distinction is made between gallbladder stones and bile duct stones. Women are more likely to have gallstones than men.
  • Risk factors: mainly female, overweight (fat), fertile (fertile), 40 years and more (forty), light-haired (fair), family predisposition (family).
  • Symptoms: None or more or less severe symptoms, depending on the location and size of the gallstones, e.g. pain in the right upper abdomen through to severe biliary colic, inflammation of the gallbladder (cholecystitis), bile stasis with inflammation of the bile duct ( cholangitis ), jaundice (icterus) and/or inflammation of other organs.
  • Possible consequences: inflammation of the pancreas (acute pancreatitis); Injury to the gallbladder wall with leakage of bile into the abdomen and resulting peritonitis ; increased risk of gallbladder and bile duct cancer.
  • Treatment: surgery, medication, shock wave therapy

Gallstones: description

Gallstones are crystallized components of the bile (bile for short ) . This fluid is produced in the liver and collected in the gallbladder, just a few centimeters long, just below it. When needed, bile is sent through the bile duct to the small intestine , where it aids in the digestion of fat.

The main component of bile is water at about 80 percent. In addition, there are bile acids, proteins and bilirubin (yellowish breakdown product of the red blood pigment hemoglobin ). Bile also contains cholesterol. Both bilirubin and cholesterol can crystallize – the result is the finest stones, a few millimeters in size (grit) or gallstones up to several centimeters in size. Doctors then speak of cholelithiasis .

Types of gallstones

Depending on which substance predominates in the gallstones, physicians distinguish between the following two main groups:

  • Cholesterol stones: These consist mainly of cholesterol and are responsible for about 80 percent of all gallstones in Germany.
  • Bilirubin (pigment) stones: They consist of a cholesterol core to which bilirubin has attached. Bilirubin stones cause about 20 percent of gallstone disease.

Another distinguishing feature is the location of the gallstones. A distinction is made between:

  • Gallbladder stones (cholecystolithiasis): They develop in the gallbladder, the collecting basin for the bile.
  • Bile duct stones (choledocholithiasis): They are located in the passage between the gallbladder and the small intestine. Sometimes they are made on the spot. Often, however, they are actually gallbladder stones that have been washed out into the bile duct (secondary gallbladder stones).

Frequency of gallstones

An estimated 5 to 25 percent of the population has gallstones. Women are affected two to three times more often than men. In addition, the risk of gallstones increases significantly from the age of 40.

Many sufferers do not even know that they have gallstones because they do not (yet) cause any symptoms.

Gallstones: causes and risk factors

Gallstones form when the bile changes in such a way that less soluble components such as cholesterol or bilirubin flocculate. Then tiny crystals form, which unite over time and continue to grow – to form grit or gallstones. In most of those affected, several factors contribute to the formation of gallstones (multifactorial genesis). Only very rarely is there a single trigger (e.g. a genetic defect that inevitably leads to the formation of gallstones).

Risk factors of the 6-f rule

Certain risk factors favor the development of gallstones. The most important can be summarized in the so-called 6-F rule:

  • female _
  • fat (overweight)
  • f ertile (fertile, multiple children)
  • forty (age 40 and over)
  • f air (blonde, light-haired)
  • f amily (familial disposition)

The fact that gallstones run more frequently in some families speaks for the influence of genetic factors : For example, a certain variant of the ABCB4 gene can increase the risk of gallstones. This gene contains the blueprint for a molecular pump that transports cholesterol from the liver cells to the bile ducts. In carriers of the gene variant mentioned, the composition of the bile is altered in such a way that gallstones form more easily.

Very rarely, there is a genetic defect that always leads to the formation of gallstones.

Other risk factors

Other risk factors for developing gallstones are:

  • pregnancies
  • Taking female sex hormones, for example as contraceptives ( the pill ) or as hormone replacement therapy during menopause
  • certain other medicines such as ceftriaxone (an antibiotic) or somatostatin (used for the hormone disorder acromegaly or upper digestive tract bleeding)
  • Stagnation of bile with impaired mobility of the gallbladder (the gallbladder cannot contract properly, the bile builds up and gallstones form more easily)
  • Bile acid loss syndrome (disease with a relevant deficiency of bile acids, e.g. as a result of surgical removal of a large part of the small intestine – e.g. in Crohn’s disease)
  • diabetes mellitus
  • Cirrhosis of the liver (e.g. due to high alcohol consumption)
  • increased blood fat levels (triglycerides, cholesterol)
  • severe overweight ( obesity )
  • Severe weight loss within a short period of time, e.g. with a reduction diet (diet in which less energy is consumed than the body actually needs) or surgical stomach reduction (in the case of severely overweight people)
  • special, high-calorie tube feed

The fact that women get gallstones more often than men is probably due to the female sex hormones. This is also supported by the fact that taking such hormones (e.g. as a contraceptive pill) and pregnancy also increase the risk of cholelithiasis.

Gallstones: Symptoms

Most people with gallstones do not experience any symptoms . This is referred to as “silent” gallstones . If at all, they are usually only discovered by chance, for example as an incidental finding of an ultrasound or X-ray examination.

Sometimes “silent” stones become “talking” over time, meaning they begin to cause discomfort. According to studies, two to four out of 100 people with gallstones develop noticeable symptoms within a year.

Symptomatic gallstones are gallstones that cause discomfort. These can be very different. In milder cases, pain and non-specific symptoms occur in the upper abdomen , such as feelings of fullness or pressure, belching and flatulence . These symptoms usually appear after a meal and can be worsened by eating fatty and/or fried foods.

Sometimes gallstones also trigger biliary colic – severe, spasmodic pain in the right middle and upper abdomen. They are wave-like : the pain increases rapidly, then reaches a plateau and then subsides spontaneously or after taking medication.

Overall, biliary colic typically lasts 15 minutes to several hours . Sometimes the pain radiates to the back and right shoulder region. Accompanying symptoms can also include sweating, nausea, nausea and vomiting.

Biliary colic occurs mainly at night and often not in the same time sequence after a meal .

About every second patient who has had gallstone symptoms such as colic before gets symptoms again within two years.

The size and location of the gallstones are decisive

Whether gallstones cause symptoms or not depends, among other things, on their size . Most are rather small, like a cherry or hazelnut, and often do not cause any discomfort. Others reach the size of a hen’s egg. Then pain is very likely.

The location of the gallstones also influences the extent to which symptoms occur. Basically, symptoms of bile duct stones are observed more frequently than with gallbladder stones. They cause colicky pain when they get stuck in the bile duct and block it – the bile can then no longer flow into the small intestine. Gallbladder stones cause colic when the stones block the way the gallbladder exits into the bile duct or its opening into the duodenum . Again, the gallbladder fails to push bile into the small intestine, leading to increased, painful contractions.

Physicians refer to the build-up of bile as a result of an obstruction in the flow of the gallbladder (cholestasis).

Gallstones: Complications

Gallstones can have several effects:

Inflammation of the gallbladder and possible consequences

When gallbladder stones block the outlet of the gallbladder, bile builds up in it. This can lead to an acute inflammation of the gallbladder ( cholecystitis ): The accumulated bile overstretches the gallbladder wall, the mucous membrane lining the organ becomes irritated and inflamed. Bacteria can then settle on it more easily . Signs of gallbladder infection include severe upper abdominal pain, fever , and chills.

If left untreated, acute inflammation of the gallbladder can lead to pus formation in the gallbladder (gallbladder empyema) – possibly even with partial death and thus rupture of the gallbladder wall (gallbladder perforation). In extreme cases, the peritoneum can also become inflamed (“bilious” peritonitis = “bilious” peritonitis).

The inflammation can also spread through the blood to the whole body – doctors then speak of ” blood poisoning ” (sepsis).

Sometimes the inflammation of the gallbladder is not acute, but chronic. In very rare cases, the gallbladder wall can thicken and calcify as a result – doctors speak of ” porcelain gallbladder “. The organ can then no longer contract properly. A certain form of “porcelain gallbladder” also increases the risk of gallbladder cancer .

bile duct inflammation and jaundice

When a gallstone blocks the bile duct, bile backs up in it. A possible consequence is inflammation of the bile ducts (cholangitis) with severe upper abdominal pain, fever and chills. In addition, the inflammation can lead to jaundice (icterus): Because the breakdown product of the red blood pigment – the yellow bilirubin – can no longer be excreted due to the bile stasis, it is deposited in the tissue. Especially the “whites” in the eyes and the skin can turn yellowish. In addition, the urine turns dark and the stool light.

Like gallbladder inflammation, bile duct inflammation can spread to neighboring organs.

inflammation of the pancreas

In most people, the bile duct, along with the pancreas duct, empties into the duodenum – the uppermost section of the small intestine. So if a gallstone blocks the mouth into the intestine , the secretion of the pancreas can also build up. A possible consequence is inflammation of the pancreas (acute pancreatitis) with severe upper abdominal pain, nausea, vomiting and fever.

Acute pancreatitis often subsides spontaneously. However, the same applies here: The inflammation can spread to neighboring organs.

Gallbladder and bile duct cancer

Gallstones increase the risk of gallbladder cancer and bile duct cancer – but only slightly. In addition, both types of cancer are rare: the total number of new cases in Germany each year is only around 5,000.

However, people with a certain form of the very rare porcelain gallbladder mentioned above are very susceptible to gallbladder cancer. It is therefore usually recommended that you have your gallbladder removed as a precaution.

Gallstones: examinations and diagnosis

If you suspect that you have gallstones, the doctor will first take a detailed discussion of your medical history (anamnesis). Among other things, he asks you to describe all your complaints in detail. He also asks about any previous or underlying illnesses. This is followed by a comprehensive physical examination and imaging procedures .

Imaging procedures

The most important imaging for suspected gallstones is the ultrasound examination (sonography) of the abdomen. In most cases, gallbladder stones from a size of one to two millimeters can be detected. In addition, the doctor can detect any other pathological changes in the ultrasound image. For example, in gallbladder inflammation, the gallbladder wall is thickened and layered.

However, bile duct stones cannot always be detected using a conventional ultrasound examination (via the abdominal wall). Endosonography – an ultrasound examination from the inside – achieves a better hit rate here . The doctor guides a thin, flexible tube with an ultrasound probe through the mouth , esophagus and stomach into the duodenum to the confluence of the bile and pancreatic ducts. Any bile duct stones can be easily identified through the wall of the duodenum.

A special X-ray examination, the endoscopic retrograde cholangiopancreatography ( ERCP ), can also demonstrate gallstones in the gallbladder and bile duct. In addition, smaller stones can be removed during the examination.

Another imaging method that can be used to clarify gallstones is magnetic resonance cholangiopancreatography (MRCP) . This means an examination of the bile ducts and the pancreatic duct using magnetic resonance imaging (magnetic resonance imaging, MRI).

blood test

In addition to imaging tests, blood tests are important. Abnormal values ​​can indicate complications caused by the gallstones. If, for example, gamma-GT and/or alkaline phosphatase (AP) are elevated, this can indicate a disease of the bile ducts. Bilirubin is typically elevated when a gallstone blocks a major bile duct (occlusive jaundice). Elevated levels of white blood cells ( leukocytes ) and ESR (blood sedimentation rate) may indicate inflammation of the gallbladder or bile ducts.

Further investigations if necessary

Sometimes gallstones occur under unusual conditions – for example, clustered in families, already in childhood or adolescence or repeatedly in the bile duct. Further investigations should then clarify the exact cause. For example, if a specific genetic cause is suspected, a genetic analysis can help.

Gallstones: treatment

Whether treatment for gallstones is necessary depends on where the stones are located and whether and what symptoms (such as biliary colic) they are causing. In principle, both the symptoms (symptomatic therapy) and the gallstones themselves (causal therapy) can be treated.

Therapy of biliary colic

The doctor treats acute biliary colic with antispasmodic and analgesic drugs (spasmolytics and analgesics) such as ibuprofen . If the gallbladder has become inflamed , the patient also receives antibiotics . In the first 24 hours after the onset of biliary colic, the patient is also not allowed to eat anything ( zero diet ).

In the case of acute biliary colic that lasts for several hours and is associated with very severe symptoms, you should call the emergency doctor!

Therapy of gallstones

Gallbladder stones usually only need to be treated if they cause symptoms or complications such as gallbladder infection. Bile duct stones, on the other hand, should always be treated because they often lead to complications.

remove gallstones

There are several methods for removing gallstones. Which procedure is used depends, among other things, on the location (gallbladder or bile duct) and the size of the gallstones.

Most gallstones are surgically removed . This is usually done as part of what is known as a laparoscopy . However, other surgical techniques are also available. In the case of repeated attacks of pain and acute inflammation of the gallbladder, the gallbladder is generally also removed during the procedure ( cholecystectomy ). The body then stores the bile in the bile duct.

In certain cases, an alternative to surgery is medication to treat the gallstones. The patient has to take a preparation over a long period of time that can dissolve the stones. In addition, gallstones can also be broken up with the help of shock waves ( shock wave therapy ).

Comprehensive information on the various removal methods can be found in Removing Gallstones .

Gallstones: Nutrition

With the right diet, you can prevent symptoms associated with gallstones and also prevent the formation of (new) gallstones. You should also eat as little fat as possible: dietary fat promotes biliary colic and stone formation.

In addition, you should eat a wholesome and high-fiber diet. Include whole grain products, vegetables and fruit in your diet on a regular basis. In combination with regular exercise and sport, this diet can help to maintain a healthy body weight or reduce excess fat deposits. Obesity is one of the most important risk factors for gallstones.

You can read more about how you can prevent gallstones and avoid biliary colic with the right diet in the article Gallstones – Nutrition .

Gallstones: course and prognosis

Gallstones that cause discomfort are generally fairly easy to remove. Surgery has the best prognosis. The gallbladder is often removed as well. Afterwards, relapses (with formation of gallstones in the bile duct) are relatively rare. With non-surgical treatment, the recurrence rate is higher.

In principle, the prognosis depends largely on whether risk factors for gallstones (such as obesity, high-fat diet, etc.) are eliminated or reduced or not.

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