When bile hardens

by Dr. P. PREMANJALI

Gallstones may not cause any symptoms but need to be treated.

Gallstones or Cholelithiasis (chole means ‘bile', lithia means ‘stone', -sis means ‘ process') are pebble-like substances that develop in the gall bladder, which is a pear-shaped sac located below the liver in the right upper abdomen. Gall stones form when bile liquid stored in the gall bladder hardens into pieces of stone-like material. Bile contains water, cholesterol, fats, bile salts, proteins, and bilirubin. If the liquid bile contains too much cholesterol or bilirubin it can harden into gall stones. Gall stones can be as small as a grain of sand or as large as a golf ball. The gall bladder can develop just one large stone, hundreds of tiny stones, or a combination of the two.

There are two kinds of stones: Cholesterol stones and pigment stones. Mixed stones account for 90 per cent of stones.

Causes: Excess cholesterol; Excess bilirubin; Incomplete emptying of gall bladder; Infection;

Prevention: The risk of gall stones can be reduced by regular intake of food without skipping meals; Fat free and fibre rich diet; Exercising most days of the week ; Losing weight slowly and gradually.

Risk factors

Women between the ages of 20 and 60 are most at risk of developing gallstones. Other risk factors include pregnancy, use of birth control pills and hormones therapy, rapid weight loss, obesity, a high-fat low-fibre diet, diabetes and a family history of gall stones

About 85 per cent of the patients do not show any symptoms of the problems. Chronic indigestion, which becomes worse after eating high fat foods and sudden, steady and moderate to intense pain in the upper middle or upper right abdomen are signals of gallstones. The pain may occur one to two hours after eating but also at other times, even at night. It can last about 30 minutes to several hours. Gall bladder pain usually starts in the upper right abdomen and may shift to the back between the shoulder blades or to the right shoulder. Other symptoms include nausea and vomiting and fever.

If left untreated, gallstones may cause problems like inflammation, rupture, perforation or pus formation all in the gall bladder and infection in the bile duct. It can also cause obstructive jaundice, inflammation of the pancreas and intestinal obstruction.

Diagnosis

Blood tests: For cell count and liver and pancreatic function.

Ultrasonography: The best way to detect gall stones.

Radionuclide scan (cholescintigraphy, HIDA scan): A small amount of radioactive tracer material is injected through the veins (intravenously) followed by a scan of the gall bladder

Endoscopic retrograde cholangio pancreatography (ERCP): A scope is passed via the mouth and dye is injected into the common bile duct. X-ray pictures are taken. Bile stones can also be extracted through ERCP.

Magnetic resonance cholangiopancreatography (MRCP): To diagnose blocked bile ducts.

Endoscopic ultrasound (EUS): An ultrasound transducer is placed on the tip of an endoscope and gently passed down the throat and through the stomach for more accurate images.

Treatment

No symptoms; no treatment. These “silent stones” are detected during routine medical check ups or exams for other illnesses. Symptomatic gall stones have to be treated.

Surgery: Removing the gall bladder is the preferred treatment for the majority of people. Gall bladder surgery (cholecystectomy) is one of the most common surgeries performed. The surgery can be performed either as Laparoscopy and Open surgery.

Non-surgical: Stones usually recur when non-surgical treatments are used.

Bile acid tablets: Ursodeoxycholicacid (UDCA) dissolves small cholesterol stones only and is effective only about 50 per cent of the time. It has to be taken for years.

Sound wave therapy (extracorporeal shock wave lithotripsy): This treatment uses high frequency sound waves to break up gall stones.

Percutaneous electrohydraulic lithotripsy: is time consuming and is not widely available.

Topical gall stone dissolution: It is still considered experimental and is not widely available.

Fortunately, the gall bladder is an organ people can live without. The liver produces enough bile to digest a normal diet. Once the gall bladder is removed, bile flows directly into the small intestine, instead of being stored in the gall bladder.

The writer is a Chennai-based Consultant Radiologist.