Gallstones (Symptomatic Cholelithiasis)

Gallstones, also known as symptomatic cholelithiasis, are hard, crystal-like deposits that can form in the gallbladder below the liver. They can range in size from as small as grains of sand to as large as golf balls – although small stones are much more common. In most cases, the stones remain in the gallbladder and do not cause any discomfort.

However, inflammation of the gallbladder wall can occur. This is referred to as cholecystitis. If a gallstone emerges from the gallbladder, it can block the bile duct – thus forcing the bile to overflow from the liver into the intestine. This condition is called choledocholithiasis.

The main symptom of symptomatic gallstones is pain in the upper right or middle part of the abdomen, directly below the ribcage. Usually, the diagnosis can be made quickly if a doctor collects a person’s medical history (anamnesis) and physical examination, as well as laboratory tests, and ultrasound. Treatment depends on the individual case. The overall prognosis is excellent. 1, 2, 3

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Gallstones develop when there is an imbalance in the composition of bile. Bile is formed in the liver, stored in the gallbladder, and finally released into the intestine. When someone eats a high-fat meal, the bile is needed to bind the fats from the food.

The majority of gallstones are made mostly of cholesterol and are called cholesterol stones. In these cases, the amount of cholesterol within the bile is too high and causes the formation of a solid stone.

Less commonly, there are also gallstones made up of bilirubin, a breakdown product of red blood cells, and also gallstones caused by an imbalance of bile salts, lecithin, or calcium carbonate. 3, 4, 5

The most important risk factors for the development of gallstones are: 5

• overweight
• the female sex
• age over 40 years old
• pregnancy
• European, Native American, or Hispanic descent
• family members with gallstones
• certain medications
• some pre-existing conditions – such as diabetes, sickle cell anemia, cirrhosis of the liver, cystic fibrosis, and Crohn's disease

In the majority of cases, gallstones do not cause any symptoms or problems. Symptoms typically occur when gallstones cause gallbladder or bile duct blockages. In these cases, the following symptoms may occur: 1, 3, 5

• remitting pain in the upper right part of the abdomen
• fever or chills
• nausea and vomiting
• itchiness
• yellowing of the eyes or skin (jaundice)
• light-colored stools
• dark urine.

If these symptoms occur, you should seek medical assistance as they may be signs of an infection or inflammation of the gallbladder, liver, or pancreas.

The main symptom of gallstones is pain in the upper right or middle part of the abdomen, directly below the ribcage. This pain can occur suddenly and can spread to the arm, right shoulder, back, or chest. Some people experience the pain as sharp and stinging, while for others it can be a deep pain. This is also known as colic or colic-like pain. It is often triggered by a heavy meal and can wake a person up at night. 1, 3, 4, 6, 7

The pain is sometimes confused with a heart attack. Gallstone pain usually lasts between half an hour and a few hours. The pain attacks often come in relapses and subside as the stone moves and the blockage dissolves. In some cases, the pain can subside just a few minutes after. 1, 3, 4, 6, 7

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A doctor will first make an anamnesis, in which the symptoms and the medical history will be inquired. The doctor will then carry out an extensive physical examination. The doctor can press on the upper right part of the abdomen and ask the person to take a deep breath during the examination. Pain may indicate an inflammation of the gallbladder.

After that, some tests are usually carried out to confirm the diagnosis. It is important to rule out other diseases that can sometimes cause similar symptoms, such as appendicitis, gastritis, and kidney stones. 5, 8

Diagnostic tests for suspected gallstones may include: 2, 3, 5, 8, 9

Blood test: This is done in order to:

• see if there are any signs of infection or inflammation of the bile ducts, gallbladder, pancreas, or liver .
• check the function of the liver.

Abdominal ultrasound:A rapid, non-invasive examination using sound waves to confirm the presence of gallstones in the gallbladder

• This is the most commonly used examination method for suspected gallstones.
• Inflammation of the gallbladder can also be detected in this way.

Endosonography: This is also a procedure that makes use of the advantages of ultrasound technology.

• The device consists of a flexible tube at the end of which an ultrasound probe is attached.
• The examiner first inserts the tube into the mouth and then pushes it forward into the abdomen so that an ultrasound image can be obtained at close range.
• The diagnosis can thus be confirmed.

Endoscopic retrograde cholangiopancreaticography (ERCP): This is the preferred method if a stone is suspected to block the bile duct.

• This examination method uses an endoscope.
• The examiner moves the endoscope through the person’s throat and esophagus into the stomach and upper intestines.
• In addition, the examiner can accurately visualize the bile duct using contrast media and if possible, remove the stone in the same session.

CT examination: This is an imaging procedure in which X-rays are used in several layers in order to:

• confirm the presence of gallstones in the bile system.
• check for possible complications, such as blocked bile ducts and pancreatitis.

MRI examination: An imaging procedure that uses a strong magnetic field to produce a detailed, three-dimensional image of the body.

Good to know: Gallstones can also be discovered by chance if you are examined for other complaints or as part of a general health check. As long as the gallstones do not cause symptoms, in this case also known as silent gallstones, treatment is usually not recommended. However, a doctor can inform you about symptoms that you should be aware of from that point on. 8, 10

In general, gallstones are usually only treated if they cause discomfort. Only roughly every fourth person who has gallstones without symptoms will develop symptoms within 10 years. 2, 5, 11

If there are complaints, a few general measures are carried out first:

• temporary fasting of food or decreasing intake of fatty foods
• administration of medications that relieve the body’s spasmodic tensions against the blockade caused by the stone
• administration of painkillers. 5

The following steps depend on the exact location of the gallstone and the problems caused.

The surgical removal of the gallbladder, called a cholecystectomy, is the preferred treatment for symptomatic cholelithiasis – i.e. when gallstones are present and lead to discomfort. It is a common procedure that is considered the most effective way to eliminate symptoms in the long term and to prevent possible complications from gallstones. 12, 13

Laparoscopic cholecystectomy: This is a type of keyhole surgery in which the gallbladder is removed through a small incision in the abdomen.

• In some cases, a person can go home on the same day.
• In other cases, you will need to stay in hospital for a few days of monitoring.

Open cholecystectomy: This is an older type of surgery that requires a larger incision in the abdomen to remove the gallbladder.

• This may be necessary if laparoscopy is not advisable or complications occur.
• The recovery time is longer with this type of surgery.

You can lead a normal and healthy life without a gallbladder. After the removal of the gallbladder, the bile flows directly from the liver into the intestine via the connecting bile duct, without being temporarily stored in the gallbladder as before. The bile continues to support digestion as usual. In some cases, mild diarrhea or digestive disorders may occur temporarily. The risk of complications from a cholecystectomy is considered low. 5, 12, 13

This procedure is the preferred treatment option for bile duct blockage. The examiner moves the endoscope into the abdominal cavity. From there, the examiner can accurately visualize the bile duct using contrast media and if possible, remove the stone in the same session. If there are further gallstones in the gallbladder, surgery is often recommended. 5, 12, 13

Non-surgical treatments are usually only recommended if surgery is not possible, e.g. if a different state of health makes surgery non-recommendable. Treatment options may include the following:

• Medications containing bile acid: This is an attempt to increase the solubility of bile and thus dissolve gallstones. The treatment period is at least six months. A recurrence of gallstones is common. 5
• Extracorporeal shock wave lithotripsy (ESWL): X-rays that emit shock waves to break gallstones into smaller pieces. Afterwards, medication must be taken to dissolve and excrete the debris. This procedure is rarely used today for gallstone treatment. 5, 12, 13

Good to know: Unfortunately, gallstones usually do not dissolve on their own. It is sometimes possible to dissolve cholesterol stones with certain medications. However, this can take a long time and often does not work. Also the nowadays rarely used method of extracorporeal shock wave lithotripsy, in which gallstones are shattered into smaller pieces (see above), can contribute to the excretion of the stones. But even if the gallstones disappear by these methods, it is likely that new stones will form over time. 3, 6, 11, 14

Most gallstones do not cause any symptoms and don’t require treatment. Whenever symptoms occur, treatment is necessary. However, the overall prognosis is excellent and most people fully recover. 13

The majority of people with gallstones have no symptoms whatsoever. In these cases, usually no treatment is necessary. Even if symptoms occur, there are low-risk treatment methods available today, which makes the prognosis extremely favorable.

In individual cases, or if no treatment is given for existing complaints, the following complications may occur: 1, 3, 5, 13

• cholecystitis (inflammation of the gallbladder)
• pancreatitis (inflammation of the pancreas)
• injury and/or infection of the bile ducts (i.e. the liver, gallbladder and bile ducts. Inflammation of the bile ducts is referred to as cholangitis.)
• intestinal obstruction.

These complications often require emergency treatment. As already mentioned above, medical attention should be sought immediately for the following symptoms: 3, 5

• severe, persistent pain in the abdomen
• fever
• chills
• yellowing of the skin or eye whites (jaundice).

Q: Can gallstones go away without surgery?

A: Unfortunately, gallstones do not usually dissolve on their own. It is sometimes possible to dissolve certain types of gallstones with certain medications. However, this can take a long time and often does not work. Also, the current, yet rarely used method of extracorporeal shock wave lithotripsy, in which gallstones are shattered into smaller pieces, can contribute to the excretion of the stones. But, even if the gallstones disappear by these methods, it is likely that new stones will form over time. 3, 6, 11, 14

Q: Are gallstones dangerous?

A: In the majority of cases, gallstones do not cause any symptoms or problems. But, you should seek medical attention immediately if the following symptoms are present: severe, persistent pain in the abdomen, fever, chills, or yellowing of the skin or eye whites (jaundice).Even if symptoms do occur, there are low-risk treatment methods available today, which makes the prognosis extremely favorable. 3, 5

In individual cases, or if no treatment is given for existing complaints, the following complications may occur: cholecystitis (inflammation of the gallbladder) pancreatitis (inflammation of the pancreas), injury and/or infection of the bile ducts, or intestinal obstruction. 1, 3, 5, 13

Q: Can you pass gallstones naturally?

A: Usually gallstones form in the gallbladder and remain there since it’s very unlikely that they will dissolve. If they pass, there are two things that can happen. Either they get stuck in the duct that connects the gallbladder to the intestine, known as the common bile duct, which leads to symptoms, such as pain. Or if they are small enough and do not get stuck in the duct, then they may cause some temporary pain. However, they will eventually reach the intestine and will be expelled.