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Gallstones

The Gallbladder

The gallbladder is a small, pear-shaped pouch about three to six inches long. It is tucked just under the liver, below the right rib cage and is connected to the intestine and liver by small tubes called bile ducts.

Bile ducts carry bile, a yellow-green fluid produced by your liver. Bile contains water, cholesterol, phospholipids and chemicals to aid digestion (bile acids), as well as waste products for excretion via the bowel, such as bilirubin1,2,3.

Bile is collected and stored in the gallbladder, and released along the bile ducts into the intestine when we eat food1. It plays a central role in helping the body digest fat. Bile acts as a detergent, breaking up the fat from food in your gut into very small droplets, so that it can be absorbed. It also makes it possible for your body to take up the fat-soluble vitamins A, D, E and K from the food passing through your gut.

What are gallstones?

Gallstones are lumps of solid material that form in the gallbladder. They usually look like small stones or gravel, but can be as small as sand or as large as pebbles, sometimes filling the gallbladder. They may take years to grow and there may be one or several.

Gallstones are formed from the chemicals in bile and may be:

  • pure cholesterol stones – these are the most common type of stone and are made up of cholesterol, which is a type of fat
  • pure pigment stones – these consist of calcium and bilirubin (a pigment from broken down red blood cells) which have solidified
  • mixed stones – these are a combination of cholesterol and pigment stones 4.

What causes gallstones?

Gallstones are formed when the different elements which make up your bile become imbalanced. Cholesterol stones form when cholesterol levels in your bile are much greater than your bile acid levels, this causes the cholesterol in your bile to solidify3.

There is evidence that dietary factors, such as diets high in cholesterol, saturated fat, refined sugar and low in fibre, increase the risk of developing cholesterol gallstones 3,5,6.

Gallstones are more common in women than in men, especially during women’s fertile years and during pregnancy. This is because cholesterol is a component of oestrogen, and at these times fluctuating levels of oestrogen need to be broken down to cholesterol and excreted in bile.

Pigment stones may form when the amount of bilirubin in bile is excessive. This can occur in conditions such as sickle cell disease3,7.

Gallstones can also form when the flow of bile is reduced. This may occur due to:

  • damage to the liver (cirrhosis) or damage to the biliary tract which affects the secretion and flow of bile3
  • long periods of fasting during which there is less requirement for bile, leading to bile stasis (decreased flow of bile)8.

What are the symptoms of gallstones?

Many people live with gallstones without symptoms and are unaware they have them until the stones show up in tests performed for another reason14.

The most common symptom of gallstones is pain in the abdomen, known as biliary colic. This is a pain that usually lasts between one and five hours (but sometimes up to eight) which can vary from mild indigestion or discomfort, to severe pain. You may feel it:1

  • in the centre of your abdomen between your breast bone and belly button
  • just under your right ribs with a sharp pain spreading to your side or shoulder blade.

Sometimes it may be mistaken for a heart attack or a peptic ulcer. This pain is due to strong contractions as the gallbladder tries to expel a stone. The pain usually begins after eating fatty foods, though it can also wake you up during the night. These attacks are usually infrequent and some people find walking about can relieve the pain.

Other symptoms may include nausea, vomiting or excessive sweating.

Symptoms which indicate a complication has arisen (complicated gallstone disease) include:1

  • a high temperature of 38oC (100.4F) or above
  • persistent pain
  • a rapid increase in the rate of your heartbeat
  • jaundice – a condition in which the whites of the eyes go yellow and, in more severe cases, the skin also turns yellow (for more information see useful words)
  • itchy skin
  • diarrhoea
  • shivering attacks – a sudden chill with severe shivering and a high temperature, similar to ‘flu’, is a sign that infection is building up
  • mental confusion
  • a loss in appetite.

When should I see a doctor?

If you have some of the symptoms listed but they last less than eight hours, you should make an appointment to see your GP.

If you have a high temperature, persistent pain (lasting longer than two hours) or jaundice, you feel like your condition is worsening or your symptoms are changing, it is important that you are seen by a medical professional. If your symptoms continue, go to A&E immediately.

Diagnosis

Asymptomatic gallstones are often found by chance during investigations of unrelated conditions14.

If you have symptoms and gallstones are suspected, your GP will ask you about the symptoms you are experiencing and may feel your abdomen to see if your liver or gallbladder is tender or enlarged. Blood tests are usually the next tests that your GP will carry out.

A sample of blood is taken by your doctor or a nurse and sent for analysis. These blood tests will look for signs of infection or inflammation. Additional blood tests known as liver function tests (LFTs) will also be done and will look for indications of inflammation, blockage of the bile ducts and damage to the liver.

The liver produces many chemicals that pass into the bloodstream; these can alter if your liver is inflamed or if bile ducts, carrying bile from the liver, are blocked. In the case of suspected gallstones, high levels of alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT) and serum bilirubin will usually be seen3,17.

If you are found to have an abnormal result, or a strong clinical history (a family history of gallstones, previous gallbladder surgery or you have risk factors for gallstones), then your GP will refer you for further tests, such as an ultrasound scan, to confirm your diagnosis4.

Treatment

If gallstones have been discovered incidentally and are not troublesome, it is often recommended to leave them alone. In this case your doctor may want to adopt a ‘watchful waiting’ policy1, which means your symptoms will be monitored to see if they progress before treatment is considered.

Some people may have one mild attack of biliary colic and no further trouble, while others have continuing problems. You may be prescribed painkillers, which you can use to control the symptoms if you experience an attack.

Waiting to see if further symptoms develop is quite common and safe but you should look out for any deterioration in your condition and report any symptoms to your GP. If your symptoms persist, your doctor will recommend that you are referred for treatment.

Acute inflammation of the gallbladder often requires admission to hospital, where you may be administered antibiotics to allow the inflammation to settle. Tests may be carried out to asses if your gallbladder requires removal.

The removal of your gallbladder is the most usual treatment for gallstones which are causing frequent and severe symptoms. Your gallbladder is not essential for life and most people notice little difference without it. It actually stops working properly when stones form, so your body has already adjusted to its loss.

T
he gallbladder is usually removed by a keyhole surgery procedure. A laparoscopic cholecystectomy is performed under a general anaesthetic using a fibre-optic tube with a tiny camera and a light on the end, called a laparoscope. A small incision in your tummy will be made and your abdomen inflated with carbon dioxide gas. Inflating your abdomen gives the surgeon a better view of your organs and more room in which to work. Instruments are then inserted into the abdominal cavity through three small incisions and controlled very precisely by the doctor, who is able to view your organs via a TV screen. The gallbladder is removed through a small cut in your navel.

Afterwards you will have a stitch or two and may have some pain, but oral painkillers are usually enough to dull this. Most people are allowed home the following day. You should have someone drive you as it is unlikely you will be fit to drive for 10 – 14 days.

When discharged, your surgeon will recommend that you take it easy for a few days. You may feel some soreness or bruising internally for a while. Generally, people are back to normal activities within two-three weeks; although this can depend on the individual and you should allow yourself time to recover.

If it is not possible to remove the gallbladder by keyhole surgery a more extensive operation or a conversion to open surgery is required.

Aftercare following surgery

For a short while after your surgery you may experience some nausea due to the anaesthetic or painkillers administered to you. You may also feel a little bloated, or have pain in your abdomen or shoulders due to the gas used to inflate your abdomen during surgery; this should usually pass within 48 hours.

On discharge you will normally be given oral painkillers for few days to control any pain and discomfort. Occasionally some people are prescribed oral antibiotics to take for a few days and your surgeon may arrange a follow-up outpatient’s appointment for four to six weeks time.

After the removal of your gallbladder, bile is no longer stored and will dribble continuously from the liver, through your common bile duct, into your intestine, rather than only being released after meals. It’s rare that you will have any change in digestive ability after having your gallbladder removed and most people notice little difference without it1.

Some people experience an increase in wind (gas passed from your rectum), bloating or increased bowel movements after meals for several weeks following the procedure. In most cases these changes are short term and will get better.

About one out of every ten people who have their gallbladder removed will experience diarrhoea; this is because the continuous release of bile salts irritates their digestive system21. This usually improves over time, but if it does not, your doctor may recommend anti-diarrhoea medicines to slow down your bowel movements. Dietary changes may also help.

Looking after yourself

There is no special diet for people with gallstones, or those who have had their gallbladders removed25. Most people do not need to change their diet at all. However, eating a good, balanced diet is one of the most important things you can do to keep yourself well. Regular low calorie meals containing protein (such as meat, fish or beans), starch (such as bread, potatoes or rice) and vitamins (in fruit and vegetables) are the best approach. The following will also help: 

  • eating plenty of fruit and vegetables: aim for 5 portions a day
  • avoiding salty foods
  • eating plenty of high-fibre foods such as brown rice, wholemeal bread and pasta
  • eating a low fat diet to avoid irritating your digestive system
  • eating a low cholesterol diet.

If you suffer from diarrhoea, eating plenty of high-fibre foods can help your body absorb excess water and make your bowel movements firmer. Avoiding spicy and fatty foods, dairy products and caffeine, may also help to reduce symptoms.

If your symptoms of diarrhoea persist, or you have any questions about your diet, talk to your GP. You can ask to be referred to a dietician for some personal advice.

Alcohol and smoking

There is no specific requirement to avoid alcohol if you have gallbladder disease. As for everyone, it is important to watch your alcohol intake and stay within the recommended guidelines (see ‘Prevention’ section). Alcohol is processed by your liver, and if your gallstones are a result of a liver condition, it is important to check with your doctor whether it is safe for you to drink any alcohol, and if so, how much.

Smoking is dangerous to everyone’s health and has been shown to increase the risk of gallbladder disease26. If you smoke, speak to your doctor about what help is available with cutting down and giving up.

Exercise

Exercise will help you to maintain a healthy weight. Some studies show that physical activity may prevent gallstones forming by improving the flow of bile27. The Department of Health recommends adults should take at least half an hour’s gentle exercise a day, leaving you warm and slightly out of breath. You can do this all at once or, if you find it easier, in shorter 10 minute bouts. If you are overweight, the amount of exercise you do may need to be increased from 30 minutes to 45-90 minutes a day to help you to lose weight28.

Finding an exercise that you enjoy will help; try walking, swimming, cycling or dancing.

If you are overweight, speak to your doctor about losing weight safely. Avoid crash diets and rapid weight loss as these rarely work and you are unlikely to maintain weight loss. They can also be dangerous and increase the risk of malnutrition and gallstones. A safe weekly rate of weight loss is between 0.5kg and 1kg (1-2lb)28.

Complementary and alternative medicines

There are a few complementary and alternative remedies available that are suggested to ease the symptoms of gallstones. At present, healthcare professionals are not clear on the role and place of these therapies in managing gallstones and gallbladder diseases.

Many products are not licensed as a medicine and therefore are not stringently regulated. This means you cannot be sure how much of the active ingredient you are getting and how pure it is. It is wise to be cautious about the claims made for herbal remedies, particularly those advertised on the internet, as they can offer false hope. It is a good idea to discuss the use of these remedies with your doctor.

Prevention

Many of the risk factors for gallstones, such as age and gender, are fixed and cannot be prevented. Others such as obesity, smoking, lack of exercise and high levels of cholesterol in your bile can be addressed by making lifestyle changes1,26.

  • Review your diet – choose foods low in cholesterol, saturated fats and sugar and opt for those high in fibre (see ‘Looking after yourself’ section)8.
  • Lose weight steadily (if you are overweight).
  • Avoid rapid weight loss.
  • Take more exercise.
  • Stop smoking26.

URSO (see ‘Treatment’ section) may be prescribed to you as a preventative measure if you are thought to be at a particularly high risk of developing gallstones, for instance, if you have recently had weight loss surgery1,5,28.

Studies have shown that drinking small amounts of alcohol may reduce cholesterol levels in bile, decreasing the risk of developing gallstones. However, drinking more than the Department of Health’s recommended guidelines for alcohol (14 units for both men and women) in a week, can lead to liver disease such as fatty liver, cirrhosis and other health problems25,26.

Some research indicates that certain oils (such as olive oil) used as part of a healthy diet may improve gallbladder emptying, and reduce gallstone formation. Garlic oil has been shown to be effective at dissolving cholesterol gallstones in the laboratory. More research needs to be done on the use of these, as dosage and effects are still not clear 5,29,30.

For more detailed information download the publication below.

Support

Please visit the support section of our website for information on Support groups in your area or visit our Useful Links section for other organisations who may be able to offer information and support.

NICE Guidance

Read the latest quality standard from NICE on the diagnosis and management of gallstone disease: http://www.nice.org.uk/guidance/qs104

Download publication


Download:  Gallstones GST 0311.pdf
 

Last Updated July 2011
Reviewed by:Mr Mohammad Abu Hilal MD FRCS PhD, Consultant, Hepatobiliary-pancreatic and Laparoscopic Surgeon, Honorary Senior Lecturer, School of Medicine, Southampton University Hospital.Mr Simon Bramhall, Consultant HPB and Liver Transplant Surgeon, University Hospital Birmingham.

To view references click here

 

 

 

 

Further information

The Trust has been donated the use of this video discussing  the physiology of Gallstones – it is aimed at medical students but after asking for feedback, some patients have also said they find it useful. It can be quite technical, so please discuss any content that you are unsure about with your medical team.