Gallstones (Cholelithiasis)

Cholelithiasis or gallstones are hardened deposits of digestive fluid (bile) synthesized by the liver, that can form in your gallbladder. The gallbladder is a small organ located just underneath the liver. The bile in the gallbladder is released into your small intestine. In the general population, 5% to 10% have gallstones, most of which are asymptomatic. Despite how prevalent gallstones maybe, more than 80% of people remain asymptomatic. Few of them are likely to develop symptoms or complications. These gallstones may go on further to develop complications such as cholecystitis (inflammation of the Gallbladder), cholangitis (infection of the biliary tree), choledocholithiasis (slipped gallstones obstructing the duct connecting to the small intestine), gallstone pancreatitis (inflammation of the pancreas), and rarely cholangiocarcinoma (cancer of biliary tree). Asymptomatic gallbladder stones with normal gallbladder and biliary tree do not need treatment unless they develop symptoms.

Depending on the causes, gallstones have different compositions. The 3 most common types are cholesterol gallstones, black pigment gallstones, and brown pigment gallstones. 90% of gallstones are cholesterol gallstones. The risk factors for the development of cholesterol gallstones are obesity, age, female gender, pregnancy, genetics, rapid weight loss, and some medications (oral contraceptives).

Patients with gallstone disease typically present with symptoms of biliary colic (intermittent episodes of constant, sharp, right upper quadrant abdominal pain often associated with nausea and vomiting), on examination either normal physical findings or tenderness can be present. Fatty and heavy meals are common triggers for gallbladder contraction. The pain usually starts within an hour after a fatty meal and is often described as intense and dull, and may last from 1 to 5 hours. However, an association with meals is not universal, and in a significant number of patients, the pain is present at night hours. When fever, increased heart rate, decreased BP, or jaundice are present, it requires a search for complications.

Ultrasound of the abdomen remains the first line and best imaging modality to diagnose gallstones. CT imaging of the abdomen can help determine choledocholithiasis and pancreatic inflammation or complications. Additionally, investigations such as endoscopic or magnetic retrograde cholangiopancreatography (ERCP/MRCP) are sometimes useful when working up patients with jaundice and dilated biliary duct or suspected cholangitis, but are usually obtained after an ultrasound. Initial labs to evaluate gallstones often include complete blood count (CBC), Liver Function test (LFT), PT/INR, lipase, amylase, and urine analysis.

Asymptomatic gallstones require the patient to be counseled regarding symptoms of biliary colic and when to seek medical attention. Patients should also be offered dietary advice to reduce the chance of recurrent episodes and referred to a general surgeon for elective laparoscopic cholecystectomy. Patients with symptoms and workup consistent with acute cholecystitis will require admission to the hospital, surgical consult, and intravenous antibiotics. Today, laparoscopic cholecystectomy is the standard of care & requires 2 to 3 days of hospitalization. Patients with choledocholithiasis or gallstone pancreatitis will also require admission to the hospital, gastro consultation, and ERCP or MRCP.

Dr. Vishwanath M Pattanshetti
MBBS, MS, FIAGES
Vice-Principal and Professor of Surgery,
Consultant laparoscopic surgery