What causes Gallstones?

The Gallbladder is a sac, which stores bile and lies beneath the liver. Bile is made by the liver and contains bile pigments, bile salts, lipids and cholesterol. Bile is released into the duodenum (first part of the small bowel) to help digest fats. The Gallbladder forms gallstones due to an imbalance between the constituents of bile and they can be predominantly made of bile pigments or cholesterol but are commonly mixed stones.

Who commonly presents with Gallstones?

Gallstones are associated more with women than men (Fair, Fertile, Female's in their Forties). Gallstones occur in approximately 20% of women and 12% of men (this may be because the female hormones cause more cholesterol to be excreted in the bile).

However, the majority of gallstones do not require any treatment with only 20% of patients who have gallstones undergoing surgery.

Any individual can develop Gallstones but factors, which increase the risks, include:

  • Use of the oral contraceptive pill
  • Pregnancy
  • Overweight and obese individuals
  • Undergoing obesity surgery
  • Patients with diabetes
  • Certain blood disorders (Haemolytic Anaemia)
  • Inflammatory bowel disease (Crohn's).
  • Age - chance of developing gallstones increases with age
  • Ethnicity - American Indians have the highest incidence of gallstones in the world

How do Gallstones present?

Gallstones may not cause any symptoms and only discovered by chance while testing for other conditions. They can however, cause symptoms such as:
Biliary Colic - this is pain experienced predominantly in the upper right abdomen. This pain is usually constant in nature, can also radiate through or around to the back and between the shoulder blades and can last from between 1 to 3 hours. The pain can also be associated with nausea. The symptoms of biliary colic are commonly associated with and brought on by the consumption of 'fatty' or rich foods.

Sometimes gallstones manifest themselves as chronic indigestion which may include abdominal bloating, flatulence and nausea especially after a fatty meal. However these symptoms may also be associated with gastro-oesophageal reflux.

Acute cholecystitis - Gallstones can also cause acute inflammation/ infection of the Gallbladder. Acute cholecystitis will present with symptoms of pain as well as a fever and sweating.

Jaundice - this is yellow skin discolouration, which occurs when a stone from the gallbladder enters the main bile duct and is unable to pass through into the duodenum. A simple specialised camera test called an ERCP (Endoscopic Retrograde Cholangio-pancreatography) is required to remove the stone but most patients can safely undergo removal of the stone by keyhole surgery at the same time as the gallbladder is removed (see below).

Pancreatitis - small gallstones or 'sludge' can pass into the bile ducts and block the main pancreas duct resulting in acute pancreatitis. This is a condition that usually presents with severe abdominal pain, nausea and vomiting. Pancreatitis tends to be treated in hospital with painkillers and fluids to allow the symptoms to settle, following which, the gallbladder is removed, by keyhole surgery.

How are Gallstones diagnosed?

Ultrasound: The most sensitive test performed when gallstones are suspected is the ultrasound examination. Ultrasound machine utilises sound waves to create images of the gallstones and other organs. The sound waves from the machine bounce off the gallstones and other organs and the images are captured on a video monitor.

Magnetic resonance cholangiogram (MR scan): is used to diagnose suspected bile duct stones. It is non-invasive and is used when the suspicion of bile duct stone is high.

Endoscopic Ultrasound (EUS): can be used to diagnose stones from the bile duct as well as biliary sludge. It involves passing a flexible camera tube down the throat into the small intestine (duodenum). The flexible camera has an ultrasound probe at its tip which can accuarately diagnose both stones in the gallbladder and bile ducts. It is sometimes combined with an ERCP which is designed to remove bile duct stones.

Computed tomogram (CT/ CAT scan): sometimes is used mainly in the evaluation of complications of gallstones.

How are Gallstones treated?

Once Gallstones are diagnosed keyhole surgery, Laparoscopic Cholecystectomy, is offered to remove the gallbladder. Surgery is performed under a general anaesthetic using four small incisions in the abdominal wall. A miniature camera and special thin instruments are inserted. The abdominal organs are inspected and the gallbladder identified. All surgery is performed inside the abdomen with the entire gallbladder containing the stones removed.  The skin is closed using dissolving stitches. In some people there may be some minor bruises in the first week, which usually settles down.

The advantages of laparoscopic approach include:

  • Less postoperative pain
  • Reduced hospital stay
  • Quicker physical recovery
  • Less wound scarring

Occasionally as happens in 2% of patients, it may not be possible to complete the procedure using the keyhole approach. The operation will therefore be converted to an open procedure. Your surgeon will discuss this with you prior to surgery.

What are the main risks of surgery?

Your surgeon will advise on any specific complications and risks. For all types of surgery there is always a risk of wound infection. Specifically for laparoscopic cholecystectomy there is always a small risk of undergoing an open operation instead of keyhole in 2% of patients. Your surgeon will discuss this with you prior to surgery.

What happens after surgery?

You will be able to eat and drink on the day of the operation. The operation is usually straightforward and most people are usually well enough to go home within twenty four hours. Most people should be well enough to engage in gentle sporting activities in 7 to 10 days.

There is no special dietary restriction following gallbladder removal and you can live without your gallbladder. In a small minority of individuals (1%), there may be increased bowel frequency following gallbladder removal because bile flows directly into the intestine from the liver but this usually settles down most of the time.

Driving can be resumed after 7days but do check with your insurance company first for appropriate cover.

Most patients fully recover from surgery between two to three weeks.