Gallstones: Description, causes, symptoms
Gallstones are crystallized components of the bile. They can develop in the gallbladder or bile duct, favoured by factors such as obesity, female sex and family predisposition. In most cases gallstones do not cause any complaints. Depending on their location and size, however, they can also cause pain – from moderate discomfort in the right upper abdomen to severe biliary colic. Read more about the frequency and signs of gallstones, treatment, nutritional tips and prognosis here!
- What are gallstones? Crystallized components of the bile in the form of tiny stones (semolina) or larger stones. Depending on their location, a distinction is made between gall bladder stones and bile duct stones. Gallstones are more common in women than in men.
- Risk factors: female, overweight (fat), fertile, 40 years and over (forty), fair-haired, family predisposition (family) – these risk factors together correspond to the so-called 6-f rule.
- Symptoms: Sometimes none. In other cases, more or less severe symptoms, depending on the location and size of the gallstones. Possible symptoms include pain in the right upper abdomen up to severe biliary colic, inflammation of the gallbladder (cholecystitis), bile stasis with subsequent inflammation of the bile duct (cholangitis), jaundice (icterus) and/or inflammation of other organs.
- Complications & consequences: Inflammation of the pancreas (acute pancreatitis); injury to the gallbladder wall with leakage of bile into the abdomen and resulting peritonitis; increased risk of gallbladder and bile duct cancer.
- Treatment options: Operation, medication, shock wave therapy
Gallstones are crystallized components of the bile (short: bile). This fluid is produced in the liver and collected in the gall bladder just a few centimetres long, which is located directly below. If necessary, the bile is transported via the bile duct into the small intestine, where it supports the digestion of fat.
The main component of bile is water, which makes up about 80 percent of the total. In addition, there are bile acids, proteins and bilirubin (yellowish breakdown product of the red blood pigment haemoglobin). Bile also contains cholesterol. Both bilirubin and cholesterol can crystallize out – resulting in the formation of very fine stones (semolina) measuring only a few millimeters or gallstones up to several centimeters in size. Doctors then speak of cholelithiasis.
Why gallstones can cause problems? Gallstones form when components of the bile crystallise out. If large gallstones from the gall bladder enter the bile duct, they can block it.
Types of gallstones
Depending on which substance predominates in the gallstones, physicians distinguish between the following two main groups:
- Cholesterol stones: These consist mainly of cholesterol and are responsible for the majority of all gallstone problems.
- Bilirubin (pigment) stones: They consist of a cholesterol nucleus to which bilirubin has attached itself. Bilirubin stones cause about 20 percent of gallstone diseases.
Another distinguishing criterion is the location of the gallstones. A distinction is made here between:
- Gall bladder stones (cholecystolithiasis): They are formed in the gall bladder, the reservoir for bile.
- Bile duct stones (choledocholithiasis): They are located in the connecting passage between the gall bladder and the small intestine. Sometimes they are created on site. Often, however, these are actually hall bladder stones that have been washed out into the bile duct (secondary bile duct stones).
Frequency of gallstones
About 15 percent of all women and about 7.5 percent of men develop gallstones during their lifetime. People who suffer from cirrhosis of the liver or inflammatory bowel disease are particularly at risk. Overall, the probability of getting gallstones increases with age.
Gallstones: causes and risk factors
Gallstones are formed when the bile changes in such a way that less soluble components such as cholesterol or bilirubin flocculate. Then tiny crystals form, which unite with time and continue to grow – into semolina or gallstones.
Certain risk factors favour the development of gallstones. The most important can be summarized in the so-called 6-F rule. This is an international name used as the risk factors are attributes that start with “F” in the English language:
- female (female)
- fat (overweight)
- fertile (fertile, several children)
- forty (age 40 years and over)
- fair [blond, light-haired]
- family (family predisposition)
Gallstones form more frequently in women than in men, especially in younger years. With increasing age, the gender-specific differences with regard to gallstones decrease.
The fact that gallstones are more common in some families speaks for the influence of genetic factors: Researchers have identified a gene variant that significantly increases the risk of gallstones. This involves the so-called ABCB4 gene. It contains the blueprint for a molecular pump that transports cholesterol from the liver cells into the bile ducts. In about one in ten Europeans, this gene has a specific change that significantly increases the risk of gallstones: Those affected get gallstones two to three times more frequently in the course of their lives than people without this gene variant. Apparently, the gene modification causes the pump to run constantly at full speed.
Other risk factors for the development of gallstones are:
- Taking female sex hormones (as contraceptives or hormone replacement therapy during menopause)
- low fiber, high cholesterol diet
- Metabolic diseases such as diabetes mellitus
- elevated blood lipid levels
- inflammatory bowel disease such as Crohn’s disease
- Bile acid loss syndrome (disease with relevant bile acid deficiency, e.g. after removal of a certain section of the intestine in Crohn’s disease patients)
- Taking certain antibiotics
- Diseases of the liver
- Infections of the bile ducts with bacteria or parasites
- Anaemia due to increased decay of red blood cells (haemolytic anaemia) – this produces large amounts of bilirubin, which can ultimately lead to the formation of gallstones
- extremely low calorie diet, very rapid weight loss
About three quarters of all people with gallstones feel no discomfort. This is called “silent” gallstones. They are discovered – if at all – only by chance, for example as a secondary finding of an ultrasound or X-ray examination.
Symptomatic gallstones, on the other hand, cause a wide variety of complaints. In mild cases, they cause pain and unspecific complaints in the upper abdomen such as feelings of fullness or pressure, belching and flatulence. These symptoms usually occur after a meal and can be aggravated by the consumption of fatty and/or fried foods.
Sometimes gallstones also cause severe, cramp-like pain in the right middle and upper abdomen. These biliary colics occur when gallstones block the exit of the gallbladder or get stuck in the common bile duct. The pain can radiate into the back and into the right shoulder region. Possible accompanying symptoms are outbreaks of sweating, nausea, nausea and vomiting.
Biliary colic can last between 15 minutes and five hours. It usually takes one to three days before the patient is completely free of complaints. Biliary colic is very often triggered by fatty and/or opulent meals and certain foods. These include fried foods, legumes and hard-boiled eggs. Alcohol and coffee can also promote biliary colic, as can stress. And: Those who have experienced colic once are very likely to suffer others.
Size and location of gallstones are decisive
Whether or not gallstones cause symptoms depends, among other things, on how large they are. Most of them are rather small like a cherry or hazelnut and often do not cause any complaints. Others reach the size of a chicken egg. Then pain is very likely.
The location of the gallstones also influences the extent to which symptoms occur. Basically, symptoms are more frequently observed with bile duct stones than with gall bladder stones.
Symptoms of gallbladder stones
These gallstones cause colic when the stones block the exit of the gallbladder. The gallbladder then fails to press bile into the small intestine, which leads to increased, painful contractions. In addition, gallbladder stones can irritate the mucosa of the gallbladder and thus lead to a bacterial inflammation of the gallbladder (cholecystitis). Possible signs of this are severe upper abdominal pain, fever and chills.
Symptoms of bile duct stones
Bile duct stones can also cause colic. This happens when they get stuck in the bile duct and block it. Then the bile can no longer flow into the small intestine. Instead, it congested in the bile duct. Doctors call this condition cholestasis. Visible signs as a result of the associated increased liver enzymes in the blood are:
- dark urine
- light chair
Bile stasis can cause inflammation of the bile ducts (cholangitis). Her symptoms include:
- severe upper abdominal pain
- Fever and chills
The inflammation can also spread to other organs.
Bile stasis can also develop into jaundice (icterus) when the fluid is backed up all the way to the liver. The organ is then no longer able to break down the bile pigment, so that the bilirubin level in the blood rises.
In about 80 percent of all people, the bile duct together with the excretory duct of the pancreas opens into the small intestine. If a gallstone is stuck in the common duct, the secretion of the pancreas can also accumulate. Possible consequence is an inflammation of the pancreas (acute pancreatitis).
Gallstones also increase the risk of gallbladder and bile duct cancer. However, both types of cancer are rare.
Very rarely gallstones bore through the gallbladder wall. The bile can then enter the abdomen and cause inflammation of the peritoneum (“bilious peritonitis”).
Gallstones: examinations and diagnosis
If gallstones are suspected, the doctor will first take the patient’s medical history in a detailed discussion (anamnesis). Among other things, he can have the complaints described in detail and asks about any pre-existing or underlying diseases. This is followed by a comprehensive physical examination and imaging procedures.
The most important procedure is the ultrasound examination (sonography) of the abdomen. This means that gallbladder stones that are larger than five millimetres can almost always be detected. In addition, the doctor can detect any other pathological changes in the ultrasound image. For example, in the case of a gall bladder inflammation, the gallbladder wall is thickened.
However, bile duct stones cannot always be detected by conventional ultrasound examination (via the abdominal wall). Endosonography achieves a better hit rate here. The physician inserts a thin, flexible tube with an ultrasound probe through the mouth, oesophagus and stomach to the duodenum to the junction of the bile and pancreatic ducts. Possible bile duct stones can be easily detected through the wall of the duodenum.
A special X-ray examination, the endoscopic retrograde cholangio-pancreaticography (ERCP), can also detect gallstones in the gallbladder and bile duct well. In addition, smaller stones can be removed directly.
Another imaging technique that can be used to clarify gallstones is magnetic resonance cholangio-pancreaticography (MRCP). This is an examination of the bile ducts and the pancreatic duct using magnetic resonance imaging (MRI).
In addition to imaging procedures, blood tests are important to detect gallstones and associated complications. Thus, elevated blood levels of gamma-GT and/or alkaline phosphatase (AP) indicate a disease of the bile ducts. Bilirubin levels are typically elevated when a gallstone blocks a larger bile duct (occlusive secterus). Increased readings for white blood cells (leukocytes) and blood sedimentation (blood sedimentation rate) can indicate inflammation of the gallbladder or bile ducts.
Sometimes gallstones occur under unusual conditions. These include gallstones that are common in families or occur in childhood or adolescence, as well as repeated bile duct stones. Then further investigations can clarify the exact cause. This may be hemolytic anemia or bile acid loss syndrome. If the doctor suspects a genetic vanlage (mutation of the ABCB4 gene), he can order a genetic analysis.
Whether treatment of gallstones is necessary depends on where the stones are located and whether and what symptoms (such as biliary colic) they cause. In principle, both the symptoms (symptomatic therapy) and the gallstones themselves (causal therapy) can be treated.
Therapy of biliary colic
The doctor treats acute biliary colic with antispasmodic and analgesic drugs (spasmolytics and analgesics). If the gall bladder has become inflamed, the patient is given additional antibiotics. During the first 24 hours after the onset of biliary colic, the patient must also refrain from eating (food leave).
In case of an acute biliary colic that lasts for several hours and is associated with very severe symptoms, you should call the emergency doctor!
Therapy of gallstones
Gall bladder stones usually only need to be treated if they cause symptoms or complications such as inflammation of the gall bladder. Bile duct stones, on the other hand, should always be treated, as otherwise complications often occur.
There are different methods for removing gallstones. Which procedure is used depends on the location (gall bladder or bile duct) and the size of the gallstones, among other things.
Gallstones are usually removed surgically. This is usually done in the course of a so-called laparoscopy. However, other surgical techniques are also available. In the case of repeated pain attacks and acute inflammation of the gallbladder, the gallbladder is generally also removed (cholecystectomy). In the future, the body will then store the bile in the bile duct.
An alternative to surgery in certain cases is the drug treatment of gallstones. The patient has to take a preparation over a longer period of time that can dissolve the stones. In addition, gallstones can also be shattered with the help of shock waves (shock wave therapy).
Comprehensive information on the various removal methods is provided in the article Removing gallstones.
With the right diet, you can prevent gallstones and also prevent the formation of (new) gallstones. For this you should eat as little fat as possible: Dietary fat promotes biliary colic and stone formation.
In addition, you should eat a full and balanced diet. Put whole grain products, vegetables and fruit on your menu regularly. This diet – in combination with regular exercise and sport – can help to maintain a healthy body weight and reduce excess fat deposits. Overweight is one of the most important risk factors for gallstones.
You can read more about how you can prevent gallstones and avoid biliary colic with the right diet in the article Gallstones – Nutrition.
Gallstones: course and prognosis
Gallstones that cause discomfort can generally be removed quite easily. The best prognosis has an operation. The gallbladder is often removed as well. Afterwards, relapses are relatively rare: About one in ten patients who have had their gallstones and gall bladder surgically removed develop new gallstones (now in the bile duct). The relapse rate is higher for non-operative treatment.
In principle, the prognosis depends largely on whether or not risk factors for gallstones (such as obesity, high-fat nutrition, etc.) are eliminated or reduced.