Gallbaldder and Gallstones
What is the Gallbladder?
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The gallbaldder is a small pouch, about 3-6 inches long. It is tucked under the liver and located in the right upper part of the abdomen, just below the right ribcage. The gallbladder is connected to the liver and the bowel by a system of small tubes called bile ducts. The bile ducts carry the bile, which is produced in the liver and helps with digestion of food in the intestine. The extra bile produced by the liver when we don't eat, is stored in the gallbladder in order to be used when needed, after food intake.
The gallbladder gets blood supply from a small artery which is called the cystic artery and it is connected to the bile duct system with a small duct which is called the cystic duct.​​​

​​​​What is bile?​
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Bile is a yellow-green fluid produced byt the liver. It contains water, cholesterol, phospholipids and bile acids. The bile plays a central role in helping the body digest fat. It acts as a detergent by breaking up the fat from the food into small particles that can be absorbed by the bowel. By this process, it also makes it possible for certain vitamins (called fat-soluble vitamins) to be absorbed by the bowel together with the fat. These vitamins are A, D, E and K. The bile, also helps in excreting waste produsts in the bowel, such as bilirubin.
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What are gallstones?
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Gallstones are small lumps that form in the gallbladder. They usually look like small stones or gravel, but sometimes can be as small as sand. They may take years ot form and may be one or several.
Gallstones are formed from the elements of bile and can be one of 3 types?
- cholesterol stones: they are made from cholesterol, a type of fat in bile. These are the most common type
- pigment: are formed from calcium and bilirubin
- mixed: a combination of the above
What causes gallstones?
Gallstones are formed when the elements of bile become imbalanced.
Cholesterol gallstones are formed when cholesterol levels in the bile are high. There is evidence that a diet high in cholesterol, saturated fat, refined sugar and low fibre, increases the risk for developing cholesterol gallstones.
Gallstones are more common in women than in men, especially during fertile years and pregnancy. This is because during these periods the flactuating levels of oestrogen are broken down to cholesterol which is excreted in bile.
Pigment stones are formed when the amount of bilirubin in bile is high. This can occur in conditions with high recycling of red blood cells, such as cycle cell disease.
Gallstones can also occur due to low flow of bile. This can happen when the bile ducts or the liver is damaged (cirrhosis) or in long periods of fasting.
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What are the risk factors for getting gallstones?
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Gallstones are very common. About 1 in 4 women and 1 in 8 men will get gallstones during their life. Known risk factors are:
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being overweight
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recent loss of weight (as a result of diet or weight loss surgery)
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age more than 40 years
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pregnancy
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oral contraceptives or oestrogen therapies
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digestive disorders, such as Crohn's, irritable bowel or metabolic syndrome
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cirrhosis of the liver
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diseases of the bile ducts, such as primary sclerosing cholangitis and primary biliary cirrhosis
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previous upper abdominal operations
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family history of gallstones
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What are the effects and symptoms of gallstones? ​
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Asymptomatic gallstones
Many people live with gallstones without even knowing it, as they do not cause them any symptoms. Sometimes the gallstones can be picked up during scans for other reasons.
Uncomplicated gallstones
The smaller and fewer the gallstones the easier it is to float within the gallbladder without any problems. Sometimes however, these stones can block the duct of the gallbladder (the cystic duct) and cause pain. This pain is located in the right upper part of the abdomen, below the right rib cage and it is called biliary colic. It can also travel to the back and right shoulder and often it is accompanied by nausea and vomiting. It will often need painkillers to get better and sometimes it can be so severe that will lead to a visit at the doctor or to the emergency department. The attacks typically last a few hours and happen again in the future. Over time these can lead to chronic scarring of the gallbladder called chronic cholecystitis.
Complicated gallstones​
Gallstones can sometimes cause more severe problems than biliary colic.
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Acute cholecystitis: this is infection and inflammation of the gallbladder, caused by prolonged blockage of the cystic duct
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Acute cholangitis: this is infection and inflammation of the bile ducts outside and inside of the liver, caused by obstruction of the flow of bile from the stones
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Gallbladder empyema: the gallbladder is severely infected and full of pus
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Gallbladder perforation: the gallbladder is severely infected and inflammed to the point that the wall bursts. Thankfully this is usually in a small part (small hole in the wall of the gallbladder). In this case, an abscess can be formed next to the gallbladder in the abdomen or in the liver. Sometimes the perforation is done through the wall of the gallbladder and the adjacent bowel (either colon or duodenum) to create a false connection bewtween the gallbladder and the bowel. This is called a fistula.
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Gallstone ileus: this is an obstruction of the bowel from a large gallstone that passed into the bowel a fistula (a false connection between the gallbladder and the bowel as described above).
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Acute pancreatitis: this is inflammation of the pancreas and is caused by a blockage of the pancreatic duct by the gallstones (the pancreatic duct drains at the same area as the bile duct and therefore can also be blocked by the stones).
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Mirizzi: sometimes the stones in the gallbladder can compress the adjacent bile duct from the outside, causing problems with the flow of bile from the liver to the bowel. This is called Mirizzi syndrome. In severe cases, the gallstones can errode from the gallbladder into the bile duct, creating a flase connection.
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Chronic cholecystitis: chronic inflammation and scarring of the gallbladder caused by repeated attacks.
In cases of complicated gallstones, further symptoms in addition to pain can be experienced, such as high temperature, shiveres, rapid heart rate (tachycardia), loss of appetite, confusion, generalised and severe abdominal pain, yellow eyes and yellow and itchy skin (jaundice). ​
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How are gallstones diagnosed?
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Asymptomatic gallstones are found by chance duering tests for unrelated conditions. If someone is suspected to have gallstones due to symptoms, inital investigations include blood tests and an ultrasound scan. This is a diagnostic test that uses sound waves. Most stones are visible on an ultrasound. You will be asked to not eat or drink anything for about 6 hours before the scan, so that the gallbladder remains full and stones are easier to be detected.
Sometimes other, more specialised investigations are required.
An MRCP (magnetic resonance cholangiopancreatography) is a scan that uses a magnet to detect gallstones. This is usually done when doctors suspect stones in the bile ducts. The scan can also image the liver, the pancreas, the spleen and other internal organs.
An ERCP (endoscopic retrograde cholangiopancreatography) is an invasive procedure that utilises a camera to go down the throat and into the stomach and the first part of the bowel (the duodenum). The opening of the bile duct in the duodenum can be identifed and a special dye (contrast) is infused in the bile ducts and x-rays are taken to check for any stones. During the same procedure the stones can be also removed. As an invasive procedure ERCP carries some small risks for complications and nowadays is reserved only for removal of stones from the bile ducts after this is confirmed by usually an MRCP.
HIDA (hydroxy iminodiacetic acid) or TIBIDA (trimethylbromo iminodiacetic acid) are scans that are used to check the function of the gallbladder, ie how well the gallbladder fills up and empties. During these tests a harmless radioactive material is injected in the blood. This is then taken up by the liver and excreted in the bile. A special camera is used to detect how well the bile is then flowing through the bile ducts and how well it is filling and empties from the gallbladder. The amount of radiation used is similar to an ordinary x-ray.
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What is the treatment of gallstones?
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If gallstgones are discovered incidentally and are not causing any sympotms, no treatment is necessary. A monitoring approach can be followed and in case they start causing trouble, treatment can be considered.
Some people may have only mild and rare attacks of pain (biliary colic). In these cases also a monitoring approach can be adopted. Painkillers can be used during the attack and antibiotics are sometimes prescribed by the doctors if an infection of the gallbaldder is suspected. Lifrestyle changes, such as low fat diet and loss of weight may reduce the frequency and severity of the attacks.
In cases of severe sympotms or complicated gallstone disease, surgical removal of the gallbladder is indicated. This is called cholecystectomy and is usually performed with keyhole (laparoscopic) surgery.