Stones which form in the gallbladder are responsible for a whole spectrum of disease entities ranging from simple biliary colic to fulminant cholangitis or necrotizing pancreatitis. In order to understand this disease spectrum it is first necessary to understand the normal anatomy of the biliary tree and the function of the gallbladder and bile.

The gallbladder serves as a reservoir for bile. When we eat a fatty meal (in the US, this means every meal) a hormone called cholecystokinin is secreted by the duodenal mucosa and causes the gallbladder to contract, thus releasing the bile that then helps to digest the fat.

Bile is made in the liver and serves to aid in the digestion of fat by emulsifying fat globules such that they present a larger surface area to digestive enzymes that break them down. The bile is secreted into the bile ducts within the liver that ultimately join to form the right and left hepatic ducts. These ducts unite to form the common hepatic duct. The gallbladder is a pouch that is attached to the under surface of the liver and is connected to the common hepatic duct via the cystic duct.   After its union with the cystic duct, the common hepatic duct becomes the common bile duct that then enters the duodenum after passing a short course through the head of the pancreas. The pancreatic duct usually enters the duodenum either through a common channel with the common bile duct or through an immediately adjacent point of entry. Thus, stones which form within the gallbladder can cause symptoms by interfering with normal gallbladder function, by obstruction of the cystic duct, or by their passage out of the gallbladder and obstruction of the common bile duct or pancreatic duct.

Bile consists of varying quantities of cholesterol, lecithin, bile salts and bile pigments. Stones form when either cholesterol or bile pigments precipitate out of bile because their solubility in the remaining bile constituents is exceeded. Thus, gallstones consist of cholesterol and bile pigments in different concentration depending on the conditions under which they were formed.

The incidence of gallstones in the American population is high and increases with age. Women are more commonly affected than men and the incidence increases with pregnancy. There is most definitely a familial predisposition but it is difficult to say whether there is truly a genetic factor since most members in a family usually have similar dietary habits. In addition, certain disease states have a higher incidence of gallstone formation.

Diabetics not only have a higher incidence of stone formation, but also tend to suffer the more severe complications of gallstones, notably acute cholecystitis, particularly with gangrene. Additionally, diabetics may have an altered perception of their symptoms and thus be more difficult to diagnose.

Hereditary diseases which result in the increased destruction of red blood cells, such as sickle cell disease, hereditary spherocytosis, and others have an associated high incidence of gallstone formation. This results from the increased circulation of breakdown products of hemoglobin which are secreted in the bile as bile pigments and pay precipitate out to form pigment stones.

Patients with Crohn's disease, a form of chronic inflammatory bowel disease, have an associated high incidence of gallstones. The reason for this is unknown.

There has been a recent trend toward younger age of presentation of patients with gallstones. I have seen this in my practice as well. It may be a true earlier presentation or perhaps just better recognition of symptoms and better diagnostic modalities.

  The classic symptoms of biliary colic are post-prandial pain in the right upper quadrant (under the ribcage) of the abdomen. This pain may radiate around to the back and there may be associated nausea and vomiting. Patients with gallstones in the absence of acute inflammation or colic may experience only fatty food intolerance with mild pain, acid reflux symptoms or diarrhea after a fatty meal.

The above symptoms with the addition of fever and chills and severe tenderness of the abdomen on physical exam implies the presence of acute cholecystitis. Here there is acute inflammation and infection present. There may be bacteria present in the bile causing the patient to become very ill. As stated earlier, diabetic patients are particularly prone to the more extreme forms of this disease and their symptoms may not be as evident as in non-diabetic patients. Though any patient who develops acute cholecystitis may go on to develop gangrene of the gallbladder, diabetic patients are particularly prone to this.

If a small stone passes out of the gallbladder it may lodge in the common bile duct causing partial or complete obstruction of that structure. Clinically, this presents as jaundice with yellow discoloration of the skin and eyes to a varying degree. There may be pain as well which is indistinguishable from that of biliary colic. The presence of fever in this clinical setting implies cholangitis which can be extremely serious. If emergency treatment is not undertaken death can result within hours.

In some cases, a stone may pass through the common duct and obstruct the outlet of the pancreatic duct which enters the duodenum nearby or with the common duct. This may result in pancreatitis. The pain is typically located in the upper mid-abdomen and radiates straight through to the back. It is usually constant rather than colicky. There may be associated nausea, vomiting and fever as well. Fortunately, pancreatitis caused by gallstones is not usually very severe and is usually self limited, but occasionally a full blown course of necrotizing pancreatitis may be encountered.

Any of the above clinical pictures may be seen alone or in combination thus sometimes making diagnosis more difficult. Nevertheless, correct and complete diagnosis is essential in all patients.

As I have begun to explain above, proper treatment depends on and begins with proper diagnosis. All patients presenting with symptoms attributable to gallstones should have an ultrasound performed. The ultrasound will assess the presence of gallstones as well as evidence of acute inflammation of the gallbladder or evidence of stones within the common bile duct. Blood tests are also done and usually include a blood cell count, chemistries, liver function tests, and tests of pancreatic enzyme levels in the blood which may be suggestive of pancreatitis if elevated.

A nuclear medicine exam such as a HIDA or DESIDA scan may be useful in determining the presence of Acute Cholecystitis. This test is very safe and involves injection of a radioactive substance intravenously. This substance is picked up by the liver and excreted into the biliary system. Under normal circumstances this substance is detected in the gallbladder, bile duct, and small bowel in a typical time related manner. In the presence of Acute Cholecystitis there is non-visualization of the gallbladder and in the case of bile duct obstruction, as with a stone, there may be a delay in excretion into the small intestine.

If there is evidence of common bile duct stones as demonstrated by the ultrasound or suggested by liver function abnormalities in the blood work, or if the patient has pancreatitis, ERCP is then indicated. Endoscopic Retrograde Cholangio-Pancreatography is performed by a Gastroenterologist with the aid of X-ray. An endoscope is passed through the stomach and into the duodenum. The entrance of the bile duct into the duodenum, called the papilla, is identified and a small catheter is introduced into the bile duct.   Contrast is then injected and X-rays are taken. If stones are found in the bile duct they may be removed with instruments passed through the endoscope. Additionally, a small incision may be made in the papilla to enlarge the entrance of the common duct into the duodenum permitting easier drainage of bile and stone fragments. This procedure may obviate the need for open bile duct surgery and its attendant complications.

The definitive treatment for symptoms of gallstones or for the prevention of recurrent passage of stones into the bile duct is surgical removal of the gallbladder. Today, Laparoscopic Cholecystectomy is the preferred method. Hospitalization following this procedure performed on an elective basis is usually only one day and recovery at home is only one to two weeks. Cholecystectomy performed via the open method usually requires four to five days in the hospital and a month recuperating at home. In some patients who have severe symptoms, acute cholecystitis or with gangrene of the gallbladder, Laparoscopic Cholecystectomy may not be able to safely be completed.

In these patients the procedure is converted to an open procedure following diagnostic laparoscopy and the cholecystectomy is completed via conventional techniques. It is difficult to predict in whom this will be necessary and I have seen many patients with severe symptoms and acute cholecystitis in whom Laparoscopic Cholecystectomy, nevertheless, is able to be safely completed. Conversely, I have also encountered patients in whom there is found to be severe inflammation or scarring or other problems making completion of Laparoscopic Cholecystectomy hazardous, in whom preoperative evaluation and work up did not predict these findings. Nevertheless, most patients, acute and chronic, warrant an attempt at Laparoscopic Cholecystectomy with the understanding that if conditions are encountered that will make the procedure too hazardous, the procedure will be converted to an open procedure. Well over 90% of patients will be able to have the procedure completed Laparoscopically and enjoy the benefits of this.

Under most circumstances, stones within the bile duct diagnosed preoperatively can adequately be treated with ERCP and papillotomy as described above. However, if the endoscopist is unable to introduce the catheter into the papilla, or is unable to remove the stones, it may be necessary to plan an open procedure to remove the gallbladder and open the common bile duct for removal of the stones. In this case a small rubber tube called a T-tube is left in the bile duct and drains bile to a bag outside the body. This tube can be removed a few weeks later of a contrast X-ray demonstrates no retained stones. If, after six weeks, small stones are still demonstrated on X-ray, they can be retrieved via the T-tube by an Interventional Radiologist who specializes in these procedures.

Having said all of this about open surgery and interventional radiology for common bile duct stones, it is indeed possible to perform the common bile duct exploration and insertion of T-tube during a laparoscopic procedure though this is technically demanding and is not successful in all cases. However, it is reasonable to try the laparoscopic approach first and convert to an open procedure as necessary. Good preoperative assessment should allow proper selection of which patients are best suited for this type of surgery.

I am frequently asked about medical treatment of gallstones. Though medications exist that do dissolve gallstones, these medications take about six months to work, are only effective in about 50% of people and when the medication is stopped the gallstones frequently return. Because of the poor results of medical management and the safety of modern gallbladder surgery, I reserve this type of management only for those patients who are a very high risk for general anesthesia.

Patients are occasionally encountered who have typical symptoms attributable to gallstones yet do not have any stones visible on ultrasound and a HIDA scan shows no evidence of acute cholecystitis or cystic duct obstruction. Many of these patients will be found to have a dysfunctional gallbladder. In this situation, although there are no stones present, the gallbladder does not contract normally in response to ingestion of fats, and symptoms are produced with eating. This entity is diagnosed by performing a HIDA scan with injection of cholecystokinin or CCK. The volume of the gallbladder before and after injection of CCK is measured and the ejection fraction is calculated. An ejection fraction of less than 40% is considered abnormal. These patients will usually obtain relief of their symptoms following cholecystectomy and a portion of these patients will in fact be found to have small stones at the time of surgery.

We have seen that the diagnosis and treatment of gallstones is not always as straight forward as one might initially think. Proper evaluation involves a team approach between the Surgeon, Gastroenterologist, and Radiologist. Nevertheless, effective minimally invasive techniques exist to treat even the most complex problems. Proper patient selection is predicated by proper preoperative evaluation and careful, complete diagnostic work up. Please visit the Laparoscopic Cholecystectomy page for more information on these procedures.