Digestive disorders

Gallstones are hard deposits in one’s gallbladder, a small organ that stores bile, which is a digestive fluid made in the liver. Gallstone disease (cholelithiasis) is one of the most common of all digestive diseases.

“After meals, the gallbladder contracts and releases bile into the intestines to aid in digestion. If the bile becomes too concentrated, hard stones are formed. The gallbladder goes into spasms and becomes inflamed, a condition called cholecystitis,” says Dr G.V. Rao, MS, MAMS, FRCS, director and chief surgical gastroenterology, transplantation services and minimally invasive surgery, Asian Institute of Gastroenterology and president, International Hepato Pancreato Biliary Association, India.

Risk factors:
Age
Gallstones are exceedingly rare in children except in the presence of hemolytic states. “Women are more likely to develop cholesterol gallstones than men, especially during their reproductive years,” says Dr Rao, adding, “Gallstones continue to form throughout adult life, and the prevalence is greatest at advanced age in men and women.”

Obesity
Obesity is a risk factor for the development of cholesterol gallstones, particularly in women with morbid obesity. “Rapid weight loss is also a risk factor for gallstone formation. High rates of gallstone formation have also been associated with very low calorie diets,” says Dr Rao.

Even diabetes mellitus is associated with an increased risk of gallstones. Other factors can be serum lipids, serum bilirubin and cirrhosis. “The increased risk of gallstone formation in these patients may be due to several factors, including reduced hepatic synthesis and transport of bile salts and non-conjugated bilirubin, high estrogen levels, and impaired gallbladder contraction in response to a meal,” says Dr Rao and adds, “Family history, genetics, oral contraceptives and even estrogen replacement therapy is also associated with higher rates of gallstones.”

Sign and symptoms
Gallstone disease may have the following four stages:
1) Lithogenic stage, in which conditions favour gallstone formation.
2) Asymptomatic gallstones stage.
3) Symptomatic gallstones stage, characterised by episodes of biliary colic.
4) Complicated cholelithiasis stage.

Symptoms and complications result from effects occurring within the gallbladder or from stones that escape the gallbladder to lodge in the CBD. Patients with asymptomatic gallstones have no abnormal findings on physical examination.

Characteristics of biliary colic include:
1) Sporadic and unpredictable episodes.
2) Pain that is localised to the epigastrium or right upper quadrant, sometimes radiating to the right scapular tip.
3) Pain that begins postprandially, is often described as intense and dull, typically lasts one to five hours, increases steadily over 10 to 20 minutes, and then gradually wanes.
4) Pain that is constant; not relieved by emesis, antacids, defecation, flatus, or positional changes; and sometimes accompanied by diaphoresis, nausea, and vomiting.
5) Non-specific symptoms (eg. indigestion, dyspepsia, belching, or bloating).
Distinguishing uncomplicated biliary colic from acute cholecystitis or other complications is important.

Key findings may include the following:
1) Uncomplicated biliary colic — pain that is poorly localised; an essentially benign abdominal examination without rebound or guarding; absence of fever.
2) Acute cholecystitis — well-localised pain in the right upper quadrant, usually with rebound and guarding; positive Murphy sign (non-specific); frequent presence of fever; absence of peritoneal signs; in severe cases, absent or hypoactive bowel sounds.
The presence of fever, persistent tachycardia, hypotension, or jaundice necessitates a search for complications, which may include the following:
1) Cholecystitis.
2) Cholangitis.
3) Pancreatitis.
4) Other systemic causes.

Diagnosis:
“Gallstones are rarely seen on plain abdominal radiographs, because only approximately 10 per cent of gallstones contain enough calcium to make them sufficiently radio-opaque, to be visible on a plain radiograph. Gallstones may be seen with abdominal computed tomography (CT) scanning though they can be missed because many stones are isodense with bile,” explains Dr Rao and adds, “Ultrasonography is the initial diagnostic procedure of choice in most cases of suspected gallbladder or biliary tract disease.”

Patients with uncomplicated cholelithiasis or simple biliary colic typically have normal laboratory test results:

1. Complete blood count (CBC) with differential
2. Liver function panel
3. Amylase
4. Lipase

Imaging modalities include:

1. Abdominal radiography (upright and supine)
2. Ultrasonography
3. Endoscopic ultrasonography
4. Laparoscopic ultrasonography
5. Computed tomography (CT)
6. Magnetic resonance imaging