Gallstones

 The gallbladder is a pear-shaped muscular organ that is 1.2 to 2.4 cm long, located in the right upper side of the abdomen, under the liver . It is connected to the liver and intestine through small tubes called bile ducts .

The primary purpose of the gallbladder is to store and concentrate bile, a greenish-brown fluid that is produced by the liver. Bile is a water-based fluid that contains bile salts, cholesterol, and other fatty substances , as well as waste products such as bilirubin, a pigment that gives bile its distinctive color. Bile is needed for digestion and absorption of fatty foods, as well as for the absorption of important fat soluble vitamins.

During fasting, the gallbladder is relaxed and the sphincter of Oddi is closed, causing the bile to flow through the cystic duct into the gallbladder, where it is stored and concentrated by absorption of water through the gallbladder wall . This allows the gallbladder to take in and store more than 10 times its volume in bile.

With meals, the entrance of fatty foods into the small intestine triggers the secretion of a hormone , which stimulates contraction of the gallbladder and the opening of the sphincter of Oddi. This results in partial emptying of the concentrated gallbladder bile through the common bile duct into the upper region of the small intestine  to aid in the digestion and absorption of fats and fat-soluble vitamins.

GALLSTONES 

 Gallstones are collections of solid material that form inside the gallbladder. Stones can form in the gallbladder if there is a change or imbalance in the composition of bile, such as too much cholesterol, increased amounts of pigment material, and/or reduced levels of bile acids, which are "detergent-like" substances that help keep cholesterol in solution. Gallstones may also result from impaired gallbladder contraction, which would lead to incomplete emptying of the gallbladder in response to a fatty meal.

Gallstones may be as small as tiny specks or as large as the gallbladder itself. The vast majority, however, are smaller than 1 inch (2.5 cm) and are one of two major types, cholesterol or pigment.

RISK FACTORS 

• Gender : Gallstones are more common in women.

• Age : The risk of gallstones increases with age. The condition is extremely rare in children and becomes progressively more frequent over time, with age 40 representing a possible cut-off between relatively low and high rates. Gallstones are present in about 10 percent of men and 20 percent of women by the age of 60.

• Ethnicity : Gallstones occur more frequently in Native Americans, Pima Indians, and Chileans.

• Family history and genetics : Studies of family histories indicate that cholelithiasis runs in certain families, suggesting that genetics has a role in gallstone development.

GALLSTONE DISEASE 

 The majority of people who have gallstones do not have symptoms; their stones remain "silent." Silent stones do not need to be treated since initial symptoms of gallstones are usually mild and the risk of surgical removal of the gallbladder is greater than the risk of delaying treatment. When gallstones begin to cause symptoms, the condition is referred to as gallstone disease.

SYMPTOMS 

 Once a patient experiences the first episode of symptoms, the chance of having further and more severe symptoms is more likely, indicating a need for treatment.

Biliary colic 

 It is characterized by episodic attacks of abdominal pain, often located in the right upper abdomen just under the lower ribs. Pain may also be felt in the back and right shoulder. Other associated symptoms include nausea, vomiting, and intolerance of fatty foods.

Acute cholecystitis 

 Recurrent biliary pain and cystic duct blockages can progress to total obstruction, causing inflammation of the gallbladder, called acute cholecystitis. Unlike biliary colic, in which symptoms abate within a few hours, pain is constant and fever is common with acute cholecystitis.

DIAGNOSIS 

 There are two aspects to the diagnosis of gallstones: determining if gallstones are present, and determining whether they are responsible for symptoms.

Gallstones are most commonly detecting using ultrasound, a painless test that uses sound waves to create an image of the gallbladder. Gallstones can also be seen on other imaging tests such as CT scan, ERCP, or endoscopic ultranography.

TREATMENT 

 Surgical treatment

   Cholecystectomy 

  Cholecystectomy is surgical removal of the gallbladder. It is one of the most commonly performed surgical procedures. Cholecystectomy requires the use of general anesthesia (medicine is given into a vein to induce sleep and prevent pain) and an operating room.

The gallbladder is an important organ, but is not essential for life. Therefore, the standard treatment for symptomatic patients who suffer from gallstones has been to surgically remove the gallbladder and gallstones. Removing the gallbladder generally has little or no effect on digestion. Loose stools, gas, and bloating may develop in about half of patients who undergo surgery; in most patients these symptoms are mild and do not require treatment

• Open cholecystectomy :Open cholecystectomy requires a 6 to 15 cm incision in the abdomen, one to three nights in the hospital, and three to four weeks to recover. The operation is safe and major complications are rare.

• Laparoscopic cholecystectomy : Laparoscopic cholecystectomy uses instruments and a small video camera, inserted into the abdomen through three or four small incisions. The instruments are used to view and remove the gallbladder. Patients may be able to go home the same day as the surgery or may stay in the hospital for one night. Patients are usually able to return to work in one to two weeks.

Laparoscopic cholecystectomy is now the standard operation for removing the gallbladder, performed in over 90 % of patients who undergo cholecystectomy.

Non-surgical treatments 

    Oral bile acid pill 

    Percutaneous electohydraulic lithotripsy 

    Extracorporeal shock wave lithotripsy 

    Topical gallstone dissolution 

    Endoscopic retrograde cholangiopancreatography (ERCP) 

 GALLSTONE RECURRENCE 

 The main disadvantage of the non-surgical treatment options is that gallstone recurrence is possible. With oral therapy, stones recur in about 50 % of patients in the first five years; recurrence occurs less often after topical gallstone dissolution. However, patients whose stones recur do not always have symptoms or require treatment.

In patients whose gallbladder is removed, stones rarely recur in the bile ducts, leading to symptoms that would require an ERCP procedure .

Gallstone prevention 

• Eat three well-balanced meals daily, with each meal containing some fat to ensure gallbladder emptying. This prevents collection of bile in the gallbladder, which is one of the risk factors for gallstone formation in susceptible individuals.

• Eat a diet that is high in fiber and calcium and low in saturated fats (fat that is solid at room temperature, eg butter, shortening, lard, meat fat).

• Maintain a normal body weight by eating an appropriate number of calories and exercising for at least 30 minutes five days per week. Obese people (with and without known gallstones) who are planning a rapid weight-loss program should be supervised by a healthcare provider and may require treatment with oral bile acids to prevent gallstone development during weight loss.