Dr. Jeff Hersh: Gallstones affect 25 percent of American women
Q: My mom had a gallstone that caused her to turn yellow and get sick, but the doctors thought surgery was too risky and recommended removing the stone with an endoscope. Why isn’t this done for everyone?
A: The liver and pancreas make various enzymes and fluids to help digest food. The gallbladder sits under the liver and stores bile, a fluid made in the liver from bilirubin, cholesterol and other substances that helps digest fatty foods. The way the “plumbing” works is that a tube from the liver (hepatic duct) merges with a tube from the gallbladder (cystic duct) to form the common duct which eventually merges with a tube from the pancreas (pancreatic duct); from there all the digestive fluids empty through the ampulla of Vater into the small intestine.
Gallstones form in the gallbladder and/or bile ducts due to an imbalance of bilirubin and cholesterol; about 10 percent are pigment stones from too much bilirubin, the remaining 90 percent are cholesterol stones. Risk factors for developing gallstones include being female, being overweight, advancing age, family history of gallstones, certain medical conditions (diabetes, Crohn’s disease, others) and others.
Gallstones are common, affecting 25 percent of American women by age 60 and 50 percent by age 75. Although less common in men, 25 percent still develop gallstones by age 75.
Fortunately, most people never develop any problems or complications from their gallstones. Small stones can pass through the ducts to the intestines with no problem, and very large stones just sit in the gallbladder.
Ten to 20 percent of the population develops symptoms from their gallstones (biliary colic), classically manifesting as right upper abdominal pain sometimes radiating to the right scapula, and often accompanied by nausea and/or vomiting. Symptoms often begin after eating a fatty meal, which stimulates the gallbladder to squirt out bile. Stones of a size that pass into the ductal system and then get stuck may block the drainage of the gallbladder, liver and/or pancreas, causing inflammation (cholecystitis, hepatitis or pancreatitis respectively) and possibly predisposing to infection.
In most cases the gallstone works its way out of the ducts on its own, the patient’s symptoms then resolving. However, for some people the stone can be firmly “stuck” and a blockage of one or more of the ducts can cause secondary complications such as pancreatitis (inflammation of the pancreas), liver compromise (sometimes leading to jaundice, a yellowing of the skin and white parts of the eyes from a buildup of bilirubin in the blood), infection or other issues.
Ultrasound is the most common test used to verify the presence of gallstones, but CT, MRI and other techniques may be required in some patients. Blood tests to evaluate pancreatic and liver function may also be needed.
Since the majority of people with gallstones do not develop any problems, no intervention is routinely needed. However, of the 10 to 20 percent of people who suffer an episode of biliary colic, about 70 percent will have another episode within a couple of years. Since the gallbladder is not absolutely needed for good health (the liver can usually secrete sufficient bile, although loose stools are more common after the gallbladder is removed), removal is often recommended after an episode of cholecystitis.
In 90 percent of cases the gallbladder is removed via a minimally invasive procedure (laparoscopic surgery) where specialized tube-like surgical instruments are inserted through small incisions in the abdominal wall. For technical reasons, some people are not a good candidate for this approach, or sometimes the laparoscopic surgery must be “converted” to an open surgery where a larger incision is needed to directly visualize the gallbladder and then remove it.
For patients whose problematic gallstone does not pass on its own, or who develop complications from a blockage of one or more of the ducts, other interventions may be needed. Some patients may require temporary drainage via a tube stuck directly through the skin into the gallbladder (a percutaneous drainage).
An endoscopic retrograde cholangiopancreatogram (ERCP) is where an endoscope (yet another type of specialized tube-like device) is passed through the patient’s mouth into their esophagus (eating pipe), then onward to their stomach and small intestine. From there, the endoscope is guided through the ampulla of Vader retrogradely (in the opposite direction the digestive fluids normally flow) into the ductal system described above. At this point, specialized X-rays may be obtained to verify the diagnosis, and certain treatments may be performed. Although the gallbladder cannot be removed with this approach, an entrapped gallstone may be “snared” and removed (using a specialized addition to the endoscope), lesions suspected of being cancer may be biopsied, an overly narrowed duct can be widened, and if indicated, a stent (a cylindrical device to keep the duct pried open) can be inserted.
Patients who are surgical candidates after their clinical condition has improved, even if an ERCP was required, may have their gallbladder removed. Other patients may be treated with medications to help dissolve their gallstones to prevent subsequent episodes of biliary colic.
The specific treatments best suited for an individual patient should be made in close consultation with a physician experienced in treating gallbladder disease. For the many people with gallstones who have not had an episode of biliary colic, a watch and wait approach is usually the best option.
Jeff Hersh, Ph.D., M.D., can be reached at DrHersh@juno.com.