What is cholelithiasis?

Cholelithiasis is a condition characterized by the formation of “stones” in the gallbladder. These stones, commonly referred to as gallstones, are hardened deposits of bile that form in the gallbladder or in the common bile duct.

Bile is a digestive fluid that consists of different compounds including bile salts, cholesterol, bilirubin, water, and electrolyte chemicals. It is produced by the liver and stored in the gallbladder that helps in fat digestion. Cholelithiasis occurs when there is an imbalance in some of these compounds in the bile.

What causes gallstone formation?

Below are the three main ways in which gallstones can occur.

  • When the bile is oversaturated with cholesterol. Normally, the bile can dissolve the cholesterol produced in the liver. But when the liver produces more cholesterol (as with obesity and diabetes) than the bile can dissolve, the excess cholesterol may form into crystals and sludge (semi-solid mass), and later into stones (cholesterol stones). Excessive production of cholesterol usually occurs with obese and diabetic people.
  • When there is excess bilirubin in the bile. Some gallstones form when the bile contains too much bilirubin, a waste product of the liver that is a component of bile. Certain hematologic conditions (i.e. sickle cell anemia) cause the liver to make too much bilirubin through the processing of breakdown of hemoglobin. Gallstones that develop from excess bilirubin are called pigment stones.
  • When the gallbladder does not empty effectively. The gallbladder usually releases bile into the small intestine to help aid in fat digestion. However, when the gallbladder has reduced motility, it does not empty effectively. This causes an accumulation of bile and an increased tendency for stone formation.

What are the risk factors for cholelithiasis?

Gallstone risk is influenced by a number of genetic and lifestyle factors. As mentioned above, the risk factors are typically related to increased cholesterol or bilirubin concentrations in bile or reduced gallbladder motility, which promote crystallization and subsequent gallstone formation. Below are the common risk factors:

  • Sex. Women are more likely to develop gallstones than men. Women who have extra estrogen in their body due to pregnancy, hormone replacement therapy NIH external link, or birth control pills may be more likely to produce gallstones.
  • Age. Older people are more likely to develop gallstones. As you age, the chance that you’ll develop gallstones becomes higher.
  • Family History. Gallstones are more than twice as common in first-degree relatives of individuals with gallstones.
  • Obesity. Obesity is associated with increased cholesterol synthesis in the liver, leading to a greater release of cholesterol into bile.
  • Rapid weight loss. Dieting increases the secretion of cholesterol into bile and may also decrease gallbladder motility.
  • Certain health conditions. Some people are more likely to develop gallstones if they have one of the following health conditions:
    • cirrhosis, a condition in which your liver slowly breaks down and stops working due to chronic, or long-lasting, injury
    • infections in the bile ducts, which can also be a complication of gallstones
    • hemolytic anemias, conditions in which red blood cells are continuously broken down, such as sickle cell anemia NIH external link
    • some intestinal diseases that affect normal absorption of nutrients, such as Crohn’s disease
    • high triglyceride levels
    • low HDL cholesterol
    • metabolic syndrome, which can also raise the risk of gallstone complications
    • diabetes and insulin resistance

What are the symptoms of cholelithiasis?

Cholelithiasis is generally asymptomatic. About 80% of patients with gallstones do not experience any symptoms at all. In fact, most people don’t even realize that they have it until the stones are found incidentally while getting treatment for another condition.

Symptoms of cholelithiasis usually only occur when the gallstone lodges in one of the tubes, called ducts, and cause temporary obstruction. In which case, you may experience any of the following symptoms:

  • Sudden and rapidly intensifying pain in the upper right portion of your abdomen
  • Sudden and rapidly intensifying pain in the center of your abdomen, just below your breastbone
  • Back pain between your shoulder blades
  • Pain in your right shoulder
  • Nausea or vomiting

The pain experienced in cholelithiasis is usually short-lived are not cause for alarm unless it progresses to further complications.

What are the possible complications of cholelithiasis?

Gallstones can cause serious problems, including:

  • Inflammation of gallbladder (acute cholecystitis). This happens when a stone gets permanently lodged in the cystic duct, causing obstruction of bile flow to small intestine. It causes constant pain and fever. Your gallbladder might burst, or rupture, if you don’t get treatment right away.
  • Blocked common bile ducts (choledocholithiasis). When a gallstone managed to get pass through the cystic duct, it can get lodged and impacted in the common bile duct. If gallstones obstruct the common bile duct, they can block the bile flow from the liver. This can cause yellowing of your skin and eyes (jaundice) or damage to liver tissue.
  • Acute pancreatitis. Gallstones can block the pancreatic duct as well. This can cause inflammation of the pancreas.
  • Infected bile ducts (acute cholangitis). A blocked duct is more likely to get infected. If the bacteria spread to your bloodstream, they can cause a dangerous condition called sepsis.

Due to the potential danger of these complications, individuals it is recommended to seek medical attention if gallstone pain does not resolve over time or if fever, jaundice, or persistent nausea and vomiting develop.

What are the treatment options?

In general, asymptomatic gallstones do not require treatment. If gallstones have been discovered incidentally and do not cause any trouble at all, your doctor may observe and monitor your symptoms first before treatment is considered.

On the other hand, gallstones that cause symptoms or complications are usually treated by surgery or non-surgical procedures that dissolve or fragment the stones.

Surgery. The primary treatment for people with recurring gallstones is gallbladder removal, or cholecystectomy. Different techniques to remove the gallbladder may be recommended depending on its site, size, and other factors.

Laparoscopic method (laparoscopic cholecystectomy) is the preferred approach to remove a gallbladder. This surgical approach is minimally invasive in which the surgeon only performs small cuts in the abdomen and uses a narrow surgical telescope to magnify the organs in the abdominal cavity. The procedure takes only one or two hours, and many patients are discharged on the same day as the surgery.

People with complications who make organ removal difficult are usually advised to undergo a traditional operation to remove the gallbladder. This traditional operation is called open cholecystectomy which requires a larger cut through the abdominal muscle to allow access to the gallbladder and bile duct.

Medication. One of the non-surgical methods to treat gallstones is the oral intake of ursodeoxycholic acid, a bile acid that reduces the secretion of the cholesterol by the liver and eventually dissolves cholesterol crystals in the gallstone. The intake of ursodeoxycholic acid is best suited for people with smaller stones (5 mm in diameter or smaller).

Shockwave lithotripsy. Cholesterol gallstones can be fragmented through shockwave lithotripsy. According to Understanding Normal and Clinical Nutrition by Sharon Rolfes et. al., “this technique uses high amplitude sound waves (called shock waves) to break gallstones into fragments that are small enough to either pass into the intestine or be dissolved with ursodeoxycholic acid. Shockwave lithotripsy can only be performed in patients with few gallstones”.

What happens when the gallbladder is removed?

The gallbladder serves as a storage facility for bile, the substance essential for fat digestion. When you eat, the gallbladder releases bile into the small intestine to break down fats. When the gallbladder is removed, there’s no place for bile to collect. What happens then is that the liver just releases bile straight into the small intestine instead of storing it first in the gallbladder, so that you can still digest most foods. However, it will be hard to digest large amounts of fatty, greasy, or high-fiber food which may lead to gas, bloating, and diarrhea. People can survive without a gallbladder, but we need to change out lifestyle such as going low-fat.

How to prevent cholelithiasis?

Cholelithiasis cannot be entirely prevented, but you can decrease your chances of developing it by following the healthy lifestyle tips below.

  • Eat a healthy diet that is high in fiber and good fats.
  • Avoid intake of refined carbohydrates, sugar, and unhealthy fats.
  • Get regular exercise. Aim for at least 30 minutes, 5 days a week.
  • Manage your weight but avoid diets that make you lose a lot of weight in a short time.
  • Drink alcohol in moderation.
  • If you’re a woman with family history of gallstones, talk to your doctor about whether you should avoid the use of hormonal birth control.
  • Talk to your doctor about cholesterol management
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  • https://www.ncbi.nlm.nih.gov/books/NBK470440/
  • https://www.niddk.nih.gov/health-information/digestive-diseases/gallstones/definition-facts
  • https://consultqd.clevelandclinic.org/gallstones-watch-and-wait-or-intervene/
  • https://www.mayoclinic.org/diseases-conditions/gallstones/symptoms-causes/syc-20354214
  • https://nutritionguide.pcrm.org/nutritionguide/view/Nutrition_Guide_for_Clinicians/1342013/all/Cholelithiasis
  • Rolfes, Sharon Rady; Pinna, Kathryn; & Whitney, Ellie. “Understanding Normal and Clinical Nutrition”. 2015. Cengage Learning. URL: https://books.google.com.ph/books?id=CV48AwAAQBAJ&printsec=frontcover#v=onepage&q&f=false