2010-08-28 / Columnists

Gallstones Are a Common Cause of Upper Abdominal Pain

Maintaining Your Health on Mackinac
By Yvan Silva, M.D.

The gallbladder is a small, globular sac located on the undersurface of the right lobe of the liver in the upper right quadrant of the abdomen. It is part of the biliary tract – a system of ducts that transports bile manufactured by the liver into the duodenum, the upper portion of the small intestine. Bile, a greenish yellow liquid, is produced by the liver and delivered into the intestine to aid in the digestion of fats and also remove waste products from the body. The secretion is constant. The gallbladder is a reservoir – it stores the bile and concentrates it six- to eight-fold. Concentration is enabled by the lining of the gallbladder, the mucosa, which absorbs water from the bile. The gallbladder contracts and delivers bile into the intestine on demand after a meal. Bile solubilizes fat into microscopic micelles, allowing their entry into the bloodstream.

When the bile becomes chemically imbalanced, solid particles begin to precipitate and form concretions or stones. Gallstones can form as small grains and may grow as large as golf balls. They often grow in crops and increase in size over a period of time. They can be solitary, or number into the hundreds. The solubility of bile becomes abnormal, leading to stone formation as well as sludge. Stagnation of these biochemical products in the gallbladder leads to the risk of acute infection of the gallbladder, potential obstruction of the bile ducts, and other complications.

The two most common types of gallstones are cholesterol stones or pigment stones. Cholesterol stones form when solubility in the bile is diminished. Pigment stones form when bile contains too much bilirubin owing to certain types of blood disorders or liver disease.

Gallstones form when bile, owing to an abnormality in the physiology of cholesterol dissolution, precipitates, leading to stone formation. Also, when the gallbladder fails to contract and empty completely, hyper-concentration of bile contributes to stone formation. Women are more than two to three times more likely than men to develop gallstones. Bile concentrations of cholesterol in women are usually higher. Estrogen, the female hormone, causes greater cholesterol excretion; birth control pills and hormone replacement therapy are also known to increase concentration and diminish contractility of the gallbladder. Pregnancy predisposes to gallstones because of both these factors. Diets high in fat and cholesterol and low in fiber, as well as “crash” diets, can cause biochemical imbalance in bile. Overweight individuals and morbidly obese individuals are at increased risk. Aging is a factor. Gallstones frequently run in families, suggesting a genetic link.

Close to a million cases are diagnosed every year, frequently with ultrasound examinations of the abdomen. More than 600,000 individuals have surgical gallbladder removal in the United States every year. Gallstones can be “silent,” or they may cause symptoms. Symptoms often begin as attacks of upper abdominal pain following ingestion of high-fat or fried foods. Raw vegetables can cause attacks. Symptoms can increase in number and in intensity, leading to medical consultation. When the gallbladder contracts to empty bile, the pent-up pressure in the biliary tract causes pain. There is the risk that small stones can be pushed into the main bile ducts, and while they may pass through into the intestine, they can become impacted in the tract at the entrance into the small intestine.

Pain in the upper abdomen, on the right side, increasing in intensity and often radiating to the right shoulder blade or back should be regarded as suspicious for an attack. When symptoms like this begin to ensue, they may include nausea and vomiting, fever, and chills, and when obstruction occurs, jaundice can ensue. This will manifest as yellowish discoloration of the whites of the eyes or the skin. Dark-colored urine and/or palecolored stools are also likely. The condition can progress into serious manifestations. Acute cholecystitis – infection of the pent-up gallbladder and potential rupture - is usually a medical emergency. Beside blockage of the bile ducts, impaction of stones can obstruct the pancreatic duct, causing acute pancreatitis – a potentially life-threatening condition.

Diagnosis can be made with ultra-sonography of the abdomen, a non-invasive test that shows the stones and the condition of the gallbladder wall and the biliary tract. Blood tests are done to identify infection and to measure the amounts of bile in the blood and damage to liver cells if that occurs. When serious impaction of the bile duct or pancreatic duct is suspected, the diagnostic and therapeutic procedure is ERCP – endoscopic retrograde cholangiopancreaticography. A flexible tube is inserted through the stomach via the mouth into the duodenum and the opening of the duct is identified. Radio-opaque dye is injected to outline the tract. Stones can be extracted using tools via the endoscope tube.

“Silent” gallstones are often discovered when tests are done for other health problems. While patients without symptoms need not have gallbladder removal, the decision for long term management is clearly related to the risk of complications without removal or the risk relating to the surgery. The onset of symptoms and frequency of attacks often herald the need for surgery. Removing the gallbladder is the most expeditious treatment. Stones will re-form if they are removed and the gallbladder is a non-essential organ. The operation of choice is the laparoscopic cholecystectomy. Small incisions in the abdominal wall are made to insert a laparoscope – a tube with a video camera in it, and surgical instruments to accomplish the removal. Often referred to as a same-day surgical procedure, recovery to normal activities is possible within a few days. When a laparoscopic attempt fails, or in advance, when it is indicated because of severe inflammation or intraabdominal scarring from previous surgery, open gallbladder removal is done through a larger abdominal incision. Recovery takes longer; hospitalization is typically three to five days, with several weeks to full activity.

Gallbladder cancer is relatively rare. When it occurs, it is associated with gallstones fouror five-fold. Symptoms may be similar to benign gallstones, but usually commence when the cancer is advanced.

Following removal of the gallbladder, the liver and the biliary system adapt to enable normal digestion. Instead of being stored in the gallbladder, bile is delivered directly into the small intestine. There may be some changes in digestion and bowel habit, but these are not lasting.

Dr. Silva is a professor of surgery at Wayne State University and a resident of Woodbluff on Mackinac Island.

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