What Is Cholelithiasis?

Cholelithiasis is the medical term for the formation of gallstones. Gallstones are calculi lodged in the gallbladder that is caused when substances in the bile harden.

The gallbladder is a pear-shaped organ located in the upper right abdomen, just below the liver. The gallbladder is responsible ¹ for storing bile. This substance is released from the gallbladder via the common bile duct to the small intestine.

The common bile duct is a tube which connects both the gallbladder and liver to the small intestine. When bile reaches the small intestine, it aids in the digestion of food and fat.

There are two types of gallstones ². Most, around 75%, gallstones are called cholesterol gallstones.

These are typically yellow in color and are mostly composed of undissolved cholesterol. The other 10-25% are called pigment gallstones. These are usually dark brown to black in color and they are caused when the bile contains too much bilirubin.

Pigment stones must be surgically removed because they are unable to dissolve while cholesterol ones can. Although gallstones can happen to anyone, they occur most often among older adults, people who are overweight, women, Native Americans, and Mexican Americans.

Symptoms and Signs of Cholelithiasis

In general, most people who have gallstones do not have any symptoms. This is because symptoms do not occur unless the stones block the function of the gallbladder, liver or pancreas.

These gallstones do not need treatment and will pass without causing harm to the body.

However, when gallstones are large enough in size or in number to block the common bile duct it can lead to a build-up of bile in the gallbladder. When too much bile builds up in the gallbladder it can cause something called biliary colic or a gallbladder attack ³.

This painful attack can last several hours and usually occurs after a large meal or at night time. Intense pain in the abdomen, vomiting, nausea, jaundice (or yellow coloring of the skin or whites of the eye), and tea-colored urine or white colored stools can indicate both the blockage of the common bile duct and the decreased function of the gallbladder, liver or pancreas.

If gallstones are left untreated and the blockage does not resolve in a few hours, the patient is at risk for developing gallstone complications.

What are the complications of gallstones?

Complications of untreated gallstones include gallbladder inflammation, gallstone pancreatitis (meaning the gallstone blockage causes the pancreas to inflame) and severe damage or infection to the bile ducts, gallbladder and/or liver. Lastly, if the blockage prolonged and is severe enough, it can result in death ⁴.

Causes of Cholelithiasis

Cholelithiasis can be caused by three things. The first is cholesterol gallstones which is caused when your bile contains too much cholesterol.

The second is pigment gallstones which are caused when your bile contains too much bilirubin.

Lastly, if your gallbladder does not empty the way it should, it could lead to a build-up of concentrated bile which can cause the formation of gallstones.

Cholelithiasis Risk Factors

Some people are at a higher risk for developing cholelithiasis than others. Not only are women, elderly individuals, overweight individuals, native Americans, and Mexican Americans more likely to develop cholelithiasis, but so are some individuals with certain medical conditions.

Individuals with conditions that impair liver function such as cirrhosis, infections in the bile ducts, various hemolytic anemias such as sickle cell anemia, any intestinal disease which impairs the normal absorption of nutrients in the intestines, Crohn's disease, low HDL cholesterol, high triglyceride levels, diabetes, and metabolic syndrome.

If you notice that you have symptoms of the development of gallstones and you have any of the above conditions, contact your physician immediately as these conditions can increase the risk for complications.

Is Cholelithiasis Hereditary?

Cholelithiasis is not hereditary, however, those who have a family member with a history of cholelithiasis are at a greater risk for developing it in their lifetime.

Diagnosis of Cholelithiasis

The diagnosis of cholelithiasis is usually done by a series of tests. First, when you arrive at the hospital, they will do a physical assessment to assess for any symptoms and signs of cholelithiasis such as abdominal pain. They will assess your vital signs and based on that assessment they will determine if you need further testing.

After a physical assessment, a physician may order laboratory tests to rule out other causes for your symptoms. A blood test that is sent to a laboratory may rule out an infection, jaundice, pancreatitis or other complications that may be caused by gallstones ⁵.

After a blood test, your physician will perform imaging tests. There are various tests with various uses for diagnosing the presence of gallstones.

Imaging Tests

First, an ultrasound can be used easily to produce an image of the structure of your organs. Ultrasound machines bounce painless sound waves off of organs inside of the body to produce their image.

If gallstones are present in the bile ducts, then they will be seen in the image produced by the ultrasound. Sometimes, silent gallstones or gallstones that are present when there are no symptoms, can be found when doing an ultrasound for other unrelated issues.

An ultrasound is the best and most accurate non-invasive tool to diagnose gallstones.

A Computed Tomography (CT) Scan uses a combination of x-rays and computer technology to produce images of the pancreas, gallbladder and bile duct. CT scans can show gallstones but they can also show other complications such as an infection or blockage of the bile ducts.

The only downfall is that CT scans may miss or not show gallstones that a patient has.

Magnetic Resonance Imaging (MRI) is another non-invasive machine that uses radio waves and magnets to create images of organs and soft tissues. MRI produces detailed images without using x-rays.

MRIs can show if there are gallstones in the ducts of the biliary tract.

Cholescintigraphy is another tool that physicians can use to diagnose the presence of gallstones, a blockage in the bile ducts or if there are any abnormal contractions of the gallbladder. Cholescintigraphy is slightly more invasive than the above imaging studies.

It uses a safe radioactive material to produce images of the biliary tract.

During this procedure, you’ll lie down on a table and your physician will inject a small amount of the radioactive substance into your vein. The may or may not also inject a substance to make your gallbladder squeeze.

Once that is done, a camera will take pictures of the radioactive substance as it moves through your biliary tract. While viewing the flow of this substance, your physician will be able to visualize any blockages that are occurring in your gallbladder.

Lastly, an Endoscopic Retrograde Cholangiopancreatography (ERCP) is the most invasive way to diagnose cholelithiasis. This imaging test combines both an upper gastro-endoscopy and x-rays to diagnose and treat problems of the bile and pancreatic ducts.

This test can help your physician locate the gallstones and remove them. This procedure requires a patient to go under anesthesia.

What Type of Lab Tests Are Most Beneficial in the Diagnosis of Cholelithiasis?

Generally, there are two types of lab tests that will be used in the diagnosis of cholelithiasis. These include liver function tests and complete blood counts. Liver function tests are a simple blood test that looks at the enzyme levels in the liver.

Abnormalities in liver function tests can indicate that there is inflammation in the gallbladder which may be caused by gallstones. Complete blood counts can rule out infection and may also indicate whether or not there is inflammation caused by gallstones in the body.

When inflammation occurs in the body or an infection is present, the white blood cell count will increase ⁶.

Can You Test for Gallstones at Home?

Patients with a history of gallstones may be able to tell when they have gallstones based on their comparison between previous symptoms and current symptoms. If a patient is educated about the symptoms of gallstones they may also be able to recognize the symptoms of gallstones without having them.

However, it is impossible to diagnose gallstones at home. Laboratory testing and image studies must be done in a hospital setting with trained professionals so that the problem can be treated properly.

Symptoms of cholelithiasis can closely relate to other diseases which is why it is important to get a confirmation from a medical professional before attempting any treatment methods.

Cholelithiasis Treatment

The best treatment for gallstones is the prevention of gallstones. If you have a history of gallstones it is important to take control of your lifestyle to prevent them from reoccurring.

You can prevent gallstones by:

• Eating foods high in fiber and healthy fats, and eating less refined carbohydrates and less sugar.
• Losing weight by maintaining healthy eating habits and regular physical activity if you are overweight or obese.

Non-Surgical Treatment Options

It is important to understand your options when diagnosed with gallstones. Although surgical options are available there are a number of reasons why nonsurgical options may be better for you. Generally, cholesterol stones have more nonsurgical treatment options than pigment stones.

• As discussed above, endoscopic retrograde cholangiopancreatography is not only a way to diagnose gallstones but it can be used to remove gallstones stuck in the common bile duct. This is more invasive than taking medication, however, it is not as invasive as surgery. Therefore, it may be a safer, cheaper and easier option.
• Another nonsurgical option is oral dissolution therapy. There are two medications, Ursodiol, and Chenodiol which contain bile acids which can break up gallstones. This treatment can take anywhere from months to years in order to break up all of the gallstones.
• Lastly, shock wave lithotripsy can use shock waves to break gallstones into smaller pieces. This procedure, however, is rarely performed. However, when it is, it can also be used alongside Ursodiol for optimal results.

Surgical Options

Since the gallbladder is not an essential organ, people can live a normal and healthy life without it. This is why the surgical removal of the gallbladder or cholecystectomy, is one of the most common operations performed in the United States among adults.

When the gallbladder is removed, bile will no longer be stored in the gallbladder. Instead, it will flow directly from the liver through the hepatic duct and common bile duct into the duodenum.

There are two types of cholecystectomies that can be performed, Laparoscopic and Open.

Laparoscopic Cholecystectomy is less invasive than open cholecystectomy. During this procedure, five small incisions will be made in the abdomen to remove the gallbladder. Once the incisions are made, a laparoscope, or a narrow instrument with a camera attached to it, will be inserted so that the physician can see inside of your abdomen.

The camera will be linked to a large screen which will aid your surgeon in the process of removing the gallbladder. This procedure is usually outpatient meaning that you can return home the same day.

After laparoscopic cholecystectomy, you can return to normal activity within a week.

Open cholecystectomy is used less often because it is more invasive than a laparoscopic cholecystectomy. This type of procedure is typically reserved for those with a severely inflamed, infected or scarred from other operations gallbladder ⁷.

Instead of five small holes being used like in a laparoscopic procedure, an open procedure uses one large incision into the abdomen to remove the gallbladder. This surgery is not outpatient and can require a hospital stay up to a week.

Recovery from this type of surgery also takes longer. After an open cholecystectomy, you can return to normal activity after approximately one month.

Cholelithiasis in Pregnancy

It is possible for cholelithiasis to occur during pregnancy. This is why it is important for pregnant women with a history of cholelithiasis to eat healthy and exercise regularly to prevent this from happening.

Although physicians used to believe that treating cholelithiasis with surgery during pregnancy would be dangerous, recent studies ⁸ show that surgical cholecystectomy does not increase fetal or maternal mortality.

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