You have pain in your upper abdomen that comes and goes especially after a meal or at night and you feel nauseous and bloated. Is this just indigestion or a sign of gallbladder disease? Do you have gallstones? More than 20 million Americans have gallstones, and women are twice as likely to develop them as men. What are gallstones and how can you prevent a gallbladder attack happening to you?
WHAT CAUSES US TO GET GALLSTONES?
The gallbladder is a small sac under the liver, (in the upper right abdomen, just beneath the rib cage). It stores bile, which is produced in the liver, in order to help us process and digest fats. After eating, the gallbladder contracts, and pushes the bile into a tube (called the common bile duct), which leads into the small intestine. The bile is composed of water, cholesterol, bile salts, as well as proteins and bilirubin (which makes it and the stools appear yellow-brown). Gallstones form if the bile contains too much cholesterol, too much bilirubin, or not enough bile salts. They are also likely to develop when the gallbladder can’t completely empty; bile just sits there, crystallizes and forms stones. Most of these stones are comprised mainly of cholesterol. These can be tiny, sand-like particles, (called “sludge”) or become as large as a golf ball. We develop symptoms if these stones block the normal flow of bile or if they lodge in the ducts, leading from the liver to the gallbladder (hepatic ducts), or leading from the gallbladder to the intestine. Since the duct from the pancreas, which carries digestive enzymes, also opens into the common bile duct, a gallstone in this location can cause these enzymes to back up and inflame the pancreas (pancreatitis).
WHY ARE WOMEN AT SUCH RISK FOR DEVELOPING GALLSTONES? ARE SOME OF US MORE LIKELY TO GET THEM?
Women, between the ages of 20 and 60 are diagnosed with gallstones twice as often as men. This is probably due to the estrogen we produce during our reproductive years. Estrogen helps get cholesterol out of our blood streams (where it can harm our arteries) by directing the liver to collect this fat and secrete it in the bile for elimination. But a high level of bile cholesterol increases the chance of forming cholesterol-containing gallstones. When we become pregnant the gallbladder, doesn’t contract or empty as well. The high cholesterol bile remains stagnant and stones are more likely to develop. The more frequently a woman completes a pregnancy, the more likely she is to have this happen.
Estrogen doesn’t have to come from our ovarian cycles or our pregnancies to have this effect. Women who take birth control pills or hormone replacement therapy, may be more likely to get gallstones, or develop additional stones, than women who do not take estrogen. Another major factor is obesity. This condition causes the gallbladder to become sluggish, the bile contains more cholesterol and less bile salts, so that cholesterol containing stones are likely to form.
Fasting. This decreases gallbladder movements so that the bile becomes more concentrated. If you skip breakfast you may be at increase risk for gallstones.
Rapid weight loss. As you lose weight your body burns up the fat and excretes cholesterol into bile, which can cause stones.
Cholesterol-lowering drugs. These increase the amount of cholesterol secreted in bile and increase risks of stones.
There is also a genetic component. Stones run in families and certain ethnic groups, especially Native Americans and Mexican Americans are at risk.
WHO IS AT RISK FOR GALLSTONES?
People over age 60
People who fast or lose a lot of weight quickly
Pregnant, women on hormone therapy and women who use birth control pills
As a medical student I was taught that there were four F’s that contributed to gallstones: Female, Fat, Forty, and Fertile.
WHAT SYMPTOMS DO GALLSTONES CAUSE?
Most stones are silent. Eighty percent of people with gallstones have no symptoms and if these stones just happen to be discovered during tests for other conditions, they usually can be ignored, unless you develop symptoms. Fewer than one percent of individuals with silent stones, develop complications from them each year.
If you do become symptomatic and have a “gallstone attack,” this is due to the fact that a stone got stuck in a duct, and the surrounding tissue became inflamed. The symptoms may subside if the obstruction is partial or the stone is expelled, or the symptoms can continue and get worse as the tissues swells and is irritated. The latter condition is called cholecystitis.
The symptoms of a gallstone attack:
Steady pain in the upper abdomen that increases rapidly and lasts from 30 minutes to several hours
Pain in the back between the shoulder blades
Pain in the upper right shoulder
Nausea or vomiting
These attacks often occur, after fatty meals or during the night. Other symptoms include:
Recurring intolerance of fatty foods
Colic (abdominal cramps)
If the inflammation progresses and the infection becomes severe, you may develop symptoms of:
Low grade fever
Yellowish color of the skin or whites of the eyes
Clay colored stools
This is a medical emergency and you should see a doctor right away.
HOW ARE GALLSTONES DIAGNOSED?
Ninety five percent of them will be seen on an abdominal ultrasound. Blood tests can also detect signs of infection of the gallbladder, pancreas, or jaundice. A CT scan (computed tomography) may also show gallstones.
If the stones are small and stuck in the bile ducts, a special x-ray in which a thin flexible scope is inserted into the duct via the mouth, (through which dye is injected) allows the doctor to locate the stones and possibly remove them. This is called ERCP (Endoscopic Retrograde Cholangiopancreatography). This should be done by a gastro-enterologist who’s practiced in the procedure.
IF THE STONES CAUSE SYMPTOMS, WHAT’S THE TREATMENT?
In most cases, it’s the surgical removal of the gallbladder, called a cholecystectomy. Each year, more than 500,000 of these procedures are done in the US. Most can be performed laparoscopically, using tiny incisions through which surgical instruments and a miniature video camera are placed into the abdomen. This method of cholecystectomy usually entails no more than one overnight stay in the hospital for recovery and a few days at home. If infection or scarring are severe and the procedure can’t be done through the laparoscope, an “open” surgery may be needed, which means a bigger scar, two to seven days stay in the hospital, and weeks of recovery at home.
DON’T WE NEED OUR GALLBLADDER?
Most of us don’t. The bile simply flows straight from the liver, into the small intestine, without being stored. This steady flow can rarely cause diarrhea.
ARE THERE NON-SURGICAL TREATMENTS?
There are medications that slowly dissolve stones over months or years (Actigall and Chenix), but they may cause diarrhea and stones can come back. The stones can also be broken up with shock waves (lithotripsy), but the small pieces can then lodge in a duct and obstruct it. And this is rarely a good medical option.
WHAT CAN WE DO TO PREVENT GALL STONES?
Don’t gain weight and don’t crash diet
Eat a healthy diet (lower saturated fat and refined carbohydrates)
Exercise (two to three hours a week can decrease risks by twenty percent)
Don’t get dehydrated
Dr. Judith Reichman has practiced obstetrics and gynecology for more than 20 years. She is a regular “Today” show contributor.