Gallstones are one of the most common causes of abdominal pain in young women. Gallstones are twice as common in women as in men(1). In England over 40,000 patients have their gall bladder taken out by operation each year(2). It is estimated that up to 3.5 million people may have gallstones in the United Kingdom. Having gallstones does not necessarily mean that patients will have problems due to them. Up to 20% of patients with gallstones may never get any symptoms related to their gallstones(3).
Types of gallstones
There are three different types of gallstones; cholesterol stones, pigment stones and mixed stones. There is no direct association between the type of stones and the symptoms that they will produce. Cholesterol stones are usually large and fewer in number and are more likely to remain asymptomatic. Whilst multiple and small stones are more likely to give rise to symptoms and complications such as jaundice and pancreatitis. It is not fully understood why gallstones are formed. It is believed that stones are formed due to the imbalance in the constituents of the bile. This results in the precipitation of constituents and eventual stone formation(4). Why this happens and why in some and not others is not fully understood.
What are the symptoms of gall stones?
The most common presentation of gallstones is abdominal pain(5). These pains start suddenly and are severe and colicky in nature and often stated as worse than labour pain. The pain starts in the epigastrium or in the right side of the upper abdomen, radiates to the back and in the region of the right scapula. It is more likely to occur after a large meal and usually last for 2 to 4 hours. These pains are called biliary colic and once resolved the patient usually feels perfectly fine. Once a patient with gallstones has had an attack of pain recurrent attacks are more likely. The second most common presentation is acute cholecystitis(6). UK Hospital Episode Statistics' data for the years 2003-2005 showed that 25,743 patients were admitted as an emergency with acute gallbladder disease during that period. There is inflammation of the gall bladder due to the blockage of cystic duct from the stones. Patients feel ill with abdominal pain, nausea vomiting and fever. The majority of patients require hospital care with intravenous antibiotics and pain killers. Once acute cholecystitis has occurred the patient requires an operation to remove the gallbladder either urgently during the same admission or at a later date with a planned operation. While waiting for an operation there is a risk of further acute attack. The chance of this happening could be reduced by avoiding fatty meals and smoking. Other less common presentations of gallstones are jaundice and pancreatitis(7). Jaundice occurs due to the blockage of the bile duct by the stones which pass in to the bile duct from gall bladder through the cystic duct. Pancreatitis is potentially a serious condition which can make patients very ill and could be life threatening.
How to diagnose gall stones?
The best way to confirm or exclude the presence of gallstones is the examination of the gallbladder and bile duct with an ultra sound machine(8). In expert hand an ultra sound examination is highly sensitive in confirming or excluding gallstone disease. Sometimes in difficult cases especially in obese patients other investigations like MR or CT scans are carried out to help with the diagnosis.
Treatment of gall stones
The best treatment for symptomatic gallstones is the removal of the gallbladder along with gallstones by surgical operation9. In the majority of patients the removal of the gallbladder results in no side effects. Up to 5% of patients may experience abdominal bloating and diarrhoea. This usually settles in few months and rarely anyone requires anti diarrhoea medication and bile salt.
The operation for the removal of the gallbladder is done by keyhole technique and is called Laparoscopic Cholecystectomy. For this operation patients require a general anaesthesia, and therefore only patients who are fit for anaesthesia can have surgery. The operation is performed through four incisions of up to one centimetre in size. This can be done either as a day case or with an overnight stay in the hospital. Recovery from the operation is quick and majority of patients can get back to day to day activities, including driving, within two weeks of the operation(9). Two per cent of patients may require an open cholecystectomy which will result in a longer stay in the hospital and prolonged recovery time of up to 6 to 8 weeks. Like any operation, gallbladder surgery caries potential risks. One serious complication is injury to the bile duct. The incidence of this is very low. I have been performing laparoscopic cholecystectomies for over 15 years and have carried out over a thousand operations, with only one bile duct injury which was successfully treated.
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2. NHS Institute for Innovation and Improvement. Focus on: cholecystectomy—a guide for commissioners. 2006.
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8. Karani J, Sutton D. Textbook of radiology and imaging Oxford: Churchill Livingstone, 2003:715.
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