Introduction

Photo of a couple eating (Wavebreakmedia Ltd / Wavebreak Media / Thinkstock)

Gallbladder surgery is one of the most common operations in Germany. About 175,000 women and men have gallbladder surgery each year, mostly because they have gallstones that are causing symptoms or complications. But gallstones are often harmless, and a lot of people don't even notice that they have them. If they do get problems, people may wonder whether to treat the symptoms or have surgery.

Gallstones form when a digestive fluid called bile thickens. The liver produces up to one liter of bile every day. It is used by the body to digest fats in the bowel. Most of the bile flows directly through the bile ducts into the small intestine after you eat. Between meals, the rest of the bile is stored and concentrated in the gallbladder. The gallbladder is a small, pear-shaped hollow organ, located in the right abdomen, just below the liver.

Illustration: Location of the gallbladder – as described in the information

Symptoms

Many people don't notice their gallstones because they have hardly any symptoms or none at all. Research has shown that about 2 to 4 out of 100 people with gallstones have noticeable symptoms within one year. About 70 out of 100 people who have already had symptoms like colic will get them again within two years. Whether someone has symptoms and what kind of symptoms they have will depend on where the gallstones have formed, how large they are, and whether they are causing any complications. If you have symptoms of gallstones, it's important to get an accurate diagnosis in order to rule out any other possible causes.

The most typical sign of gallstones is very unpleasant, cramping pain in the upper abdomen (colic). This pain occurs if the gallbladder is contracting to squeeze bile into the bowel, but gallstones are blocking the exit at the same time. The pain comes in waves and usually gets a bit better after about an hour, eventually disappearing completely a few hours later. The pain may radiate into your right shoulder and back. Gallbladder stones can also cause other symptoms, including feeling too full, flatulence, nausea, vomiting and regurgitation.

Cramping pain in the upper abdomen can also be caused by a different condition known as bile duct stones. These may lead to jaundice (sometimes called icterus) too – a condition where the skin and the whites of the eyes take on a yellowish color. Here the jaundice is caused by bile duct stones preventing proper bile drainage. This means that the liver is no longer able to break down the bile pigments, which raises the level of yellow bilirubin in the blood, causing the skin and whites of the eyes to turn yellow. This may also make urine darker, and stool may have a lighter color. 

Illustration: Gallstones – as described in the information

Causes

Bile is made up of water and several other substances, some of which are not water-soluble. If these substances clump together, gallstones form. It is believed that this happens when there is an imbalance in the substances that make up the bile. For instance, the bile often contains more cholesterol than usual. But it isn't exactly clear what causes the stones to develop. Most gallstones are made of cholesterol. Other, less common, types of gallstones are known as pigment stones. They consist of calcium and bilirubin, a yellowish pigment that is made during the breakdown of hemoglobin in red blood cells.

Gallstones can form in the gallbladder itself, and, less frequently, directly in the bile ducts. Most bile duct stones first form in the gallbladder and then migrate into the common bile duct (ductus choledochus). The medical term for gallstones in the gallbladder is cholecystolithiasis, and the medical term for gallstones in the bile ducts is choledocholithiasis.

Risk factors

The following factors are known to increase the risk of gallstones:

  • Age: The risk of developing gallstones increases with age, especially after you reach the age of 40.
  • Genes: If someone in your family has had gallstones.
  • Sex: Women are more likely to get gallstones than men. The female sex hormone estrogen is believed to increase the risk of gallstones.
  • Pregnancy.
  • Using the contraceptive pill or estrogen tablets during menopause (hormone therapy).
  • Functional problems of the gallbladder: The organ cannot contract (squeeze bile out) properly.
  • Short bowel syndrome: A disorder that can develop after surgical removal of a large segment of the small bowel.
  • Diabetes.
  • Cirrhosis: A severe liver disease caused by metabolic disorders or excessive consumption of alcohol.
  • Being very overweight.
  • Losing a lot of weight in a short time: This happens a lot in very obese people who have surgery to make their stomach smaller.
  • Special high-calorie liquid food.
  • Hemolysis: A disease that causes increased breakdown of red blood cells.

Prevalence

It is estimated that, from the age of 40, more than 20% of women and more than 10% of men have gallstones. Most of them will not have any symptoms.

Effects

If the typical symptoms arise, there is a greater risk of complications, such as obstruction of the bowel or inflammation of the gallbladder or pancreas. About 1% of people with gallstones develop complications each year.

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Diagnosis

Gallstones are sometimes found by chance, for example during an ultrasound scan of the abdomen done for other reasons. But the doctor will often specifically look for them because you have symptoms that could be signs of gallstones. Before any diagnostic tests are done, it is important to describe your symptoms to the doctor in detail.

Diagnosing gallstones is normally not very complicated. After you have talked to the doctor, you will have a physical examination and an ultrasound scan of your abdomen. This will usually be enough to make a diagnosis. More tests may be necessary to make sure the symptoms aren't being caused by other medical problems.

Diagnosing gallstones located in the bile duct may be more complicated. If there is reason to believe you might have bile duct stones, an ultrasound scan will usually be done here too. But bile duct stones are more difficult to detect on an ultrasound image. Because of this, you might then have a special x-ray examination called endoscopic retrograde cholangiography (ERC). This involves inserting an endoscope through the mouth and gently pushing it along the food pipe, stomach and into the duodenum, where the bile duct opening is found. The doctor will then inject a contrast agent into the duct so that any stones become visible on the x-ray image. The endoscope can also be used to remove stones during the procedure.

Other options include magnetic resonance cholangiography (MRC) and endoscopic ultrasound (EUS, or endosonography). MRC produces cross-sectional images of the bile duct system. Radiation isn't used in MRC or EUS. MRC doesn't require endoscopy. This means that, unlike with ERC, any stones that are discovered can't be removed during the examination. This would have to be done in a separate procedure.

Treatment

If gallstones don't cause any problems, then there's usually no need to treat them. A lot of people with gallstones don't have any symptoms for a long time. What's more, any treatment can have side effects, and surgery always carries certain risks.

People who have very large gallstones or specific types of porcelain gallbladder (calcification of the gallbladder wall) are at greater risk of developing gallbladder cancer. Surgical removal of the gallbladder may then be considered even if they don't have any symptoms.

Several painkillers and antispasmodic medications are available for the relief of painful colic. Symptoms like bloating or nausea can also be treated with medicine. But drugs that can dissolve the gallstones are used only rarely.

Removing the gallbladder is the only way to permanently prevent painful colic. Whether and when this step is taken will depend on several factors, including the severity of symptoms and the risk of complications.

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Please note that we do not provide individual advice on matters of health. You can read about where to find help and support in Germany in our information “How can I find self-help groups and information centers?”

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