What are gallstones?
Also known as cholelithiasis, gallstones are formations of the biliary tract that are present in the gallbladder. They remain asymptomatic for a very long time and develop insidiously. The associated risk is the migration of a gallstone into the cystic duct opening. During the contraction of the gallbladder, it may obstruct the bile outflow. A biliary colic develops due to the tension of the gallbladder wall. When pain persists due to cystic duct obstruction, it results in acute cholecystitis. When one or more gallstones are present in the common bile duct, it is called choledocholithiasis. This is a consequence of the migration of the gallstones from the gallbladder into the bile duct.
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The concentrations of substances present in the bile approach their limits of solubility. This presence of bile in the gallbladder gets supersaturated precipitating into microscopic crystals that get trapped in the mucus of the gallbladder producing sludge. As these crystals grow, they form into macroscopic stones. Complications arise when the sludge occludes the duct.
Gallstone formations can be divided into 4 stages:
- Lithogenic state – conditions ideal for the formation of the gallstone
- Asymptomatic gallstones – they are present in the gallbladder without causing any evident symptoms. They are discovered incidentally and coexist with gastrointestinal disorders.
- Symptomatic gallstones (onset of biliary colic) – during gallbladder contraction, the sludge propitiously impacts the cystic duct, increasing gallbladder wall tension.
- Complex cholelithiasis
- Intolerance to fat
- Postprandial epigastric pain radiating to the back and the right shoulder
- Nausea and vomiting
- Upper right quadrant tenderness
- Murphy’s sign or jaundice – yellow discoloration of the skin
- Physical examination reveals tenderness in the upper right quadrant and a palpable infiltrate is exhibited.
- Blood studies conducted should include a CBC differential count, amylase, lipase, liver function panel and blood culture.
- Abdominal radiography is taken by placing the patient in an upright and supine position. Mixed gallstones containing sufficient calcium will appear opaque on plain films.
- Ultrasonography captures gallstones as echogenic foci within the gallbladder. The study is especially useful in the diagnosis of acute cholecystitis.
- CT scan or computed tomography is used to take images of the abdominal viscera in the presence of abdominal pain.
- MRI or magnetic resonance imaging is done along with cholangiopancreatography (MRCP) for non-invasive investigation of gallstones in the bile duct and the biliary tract.
Dissolution of gallstones can be attempted with ursodiol or ursodeoxycholic acid. This suppresses the secretion of cholesterol and impedes the intestinal absorption of the cholesterol. Actigall, Urso 250, Urso Forte are all used to treat non-calcified gallbladder stones < 20 mm in diameter.
I am a surgical practitioner having treated several cases of cholelithiasis with medical as well as surgical management.