Gallstones

The gallstone is the formation of stones (commonly called “stones”) inside of the bile duct. It is a disease of the Western world, whose frequency is increasing progressively in those developing countries that are adopting Western dietary habits.

It affects more women and the elderly. It is the most frequent cause of hospital admission for digestive diseases and, although its mortality is low, in elderly patients it can lead to serious complications, derived from the advanced age of these patients.

Causes of gallstones

Gallstones are crystalline structures that are produced by the aggregation of certain components, normal or abnormal, of the bile. These calculations are divided into the following groups:

• mixed and cholesterol stones (80%)
• pigmentary stones (20%)

The formation of stones is due, in most cases, to excess cholesterol eliminated by the bile, generally associated with an excess of cholesterol in the blood (hypercholesterolemia), although it can also appear in people with normal levels of cholesterol in the blood .

Cholesterol is a relatively insoluble substance in water, which requires the presence of certain substances to prevent its precipitation in the bile. When the content of cholesterol present in the bile is higher than that which can be solubilized, its precipitation occurs and, therefore, the formation of gallstones.

Factors of the bile duct also seem to be involved in the production of stones, mainly motor disorders that cause the bile to remain more or less stagnant, favoring the aggregation of cholesterol crystals.

Once the stones are formed, there will be alterations in the excretion of bile (obstruction) or irritation of the bile duct, among others.

Symptoms of gallstones

Stone disease can manifest itself in three ways:

1. Asymptomatic: it is the most frequent (65-80% of cases). A gallstone is considered asymptomatic when the patient does not present symptoms of biliary colic or symptoms attributable to any of its complications.
2. Uncomplicated symptoms: symptoms of biliary colic will appear, with continuous abdominal pain that increases progressively in the interval from 15 minutes to an hour, forcing the person to interrupt the activity they were doing. It is located in the upper, central or right region of the abdomen, and less frequently, in the upper left or mid-thoracic region. The duration of pain is always greater than 30 minutes and less than 5 hours (if the duration is greater, an acute cholecystitis should be suspected ). Nausea, vomiting, and profuse sweating are frequently associated, as well as radiating pain to the back or right shoulder. There may be diarrhea.
3. Symptomatic and complicated: it is one in which the patient develops symptoms secondary to a biliary complication: acute cholecystitis, choledocholithiasis and gallstone ileus.

Choledocholithiasis refers to the presence of stones in the common bile duct. These stones usually come from the gallbladder (especially cholesterol), although sometimes they can form in the common bile duct primarily. The most important complication of choledocholithiasis is acute pancreatitis.

Gallstone ileus consists of an obstruction of the intestine (usually the small one) due to the impaction of the stone inside.

Currently, there is controversy regarding the relationship between the presence of gallstones and the development of gallbladder cancer, but so far no evidence has been found in favor of this relationship.

How is it diagnosed?

In the case of asymptomatic forms, the diagnosis is accidental, when performing an examination for another pathology.

In the uncomplicated symptomatic form, the diagnostic test of choice is abdominal ultrasound. It is also recommended to carry out a blood test, in order to rule out liver involvement (increased transaminases ) and high cholesterol levels.

Regarding complications, each of them requires different diagnostic procedures (blood tests, ultrasound, abdominal X-ray or abdominal CT).

Treatment of gallstones

We will distinguish here between the acute treatment of biliary colic and that of lithiasis as such.

Acute treatment of biliary colic

Absolute diet is recommended until the disappearance of symptoms, and administration of analgesics, anti-inflammatories and spasmolytics.

Treatment of lithiasis

Treatment is surgical. It consists of the removal of the gallbladder by laparoscopic surgery, unless the patient’s conditions require open abdominal surgery (laparotomy).

If the patient has had a single episode of biliary colic, he has about a 30% chance of remaining asymptomatic for the next ten years. In this case, you can choose between waiting and assessing the evolution of the condition before starting treatment, although you should also know that the surgical risk increases with age.

The treatment of complications is different depending on which one occurs. In those cases in which a choledocholithiasis and, secondarily, a biliary obstruction occurs, the removal of the stone by endoscopic retrograde cholangiopancreatography (ERCP) will be necessary.

In patients with high surgical risk, extracorporeal lithotripsy or pharmacological treatment (ursodeoxycholic acid, for example) can be considered.

How to avoid stone formation

Taking into account that most gallstones are made up of cholesterol, diet is an essential factor in the prevention of gallstones.

The diet must be varied without excess fat or cholesterol (Mediterranean diet), provided that the particular conditions of the person do not advise the indication of more restrictive diets, in order to achieve, in a high percentage of cases, that this pathology does not appear.

You should consult your family doctor in all cases of persistent abdominal pain, which does not subside within 1 to 5 hours or is accompanied by other symptoms such as fever or vomiting.

If the ultrasound does not reveal gallstones or if you have signs or symptoms that warrant surgical treatment, your doctor will refer you to a specialist in the digestive system .