The Gallstone Elimination Report

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Gallstones are common, and are estimated to be present in 20-30% of people in developed countries. Only 20-30% of these people will develop problems related to their stones, and it is important to try and differentiate between symptomatic and asymptomatic stones. Gallstones contain cholesterol, bile pigments, or a mixture of these compounds, and it is clear that their aetiology is multi-factoral. Obesity, ileal resection, and haemolytic anaemia have all been linked to gallstone formation, the only certain factors about their formation is that they are twice as common in women as men, and become increasingly common with age.

Gallstones may cause a variety of symptoms depending on which part of the body they are in. The commonest problems arise from stones in the gallbladder, and present as biliary colic or cholecystitis. Biliary colic is a self-limiting condition characterised by right upper quadrant pain, often severe, caused by temporary cystic duct obstruction. The pain is associated with nausea, and occasional vomiting, and may radiate to the back. If the pain does not settle within a few hours, and a fever and raised white cell count develop, then a diagnosis of acute cholecystitis is more likely (see Acute Cholecystitis). Unrelieved obstruction of the cystic duct may lead to formation of a muco-cele, as mucus secretions collect and produce a tense swollen gallbladder. Infection within an obstructed gallbladder results in an empyema. Stones in the CBD may cause obstructive jaundice (see Jaundice), as may stones impacted in Hartmann's pouch (Mirizzi's syndrome). Infection can occur within an obstructed biliary system, giving rise to cholangitis, associated with the classic features of Charcot's triad (pain, fever, and jaundice). This may respond to antibiotic therapy, but occasionally requires prompt drainage of the infected system too, either by ERCP, or by a percutaneous, trans-hepatic route. Gallstones passing through the extra-hepatic biliary system are one of the commonest causes of acute pancreatitis (see Acute Pancreatitis). On rare occasions a biliary-enteric fistula may develop between an inflamed gallbladder and the duodenum, stomach, or colon, and may result in stones passing into the bowel directly. If a large stone passes into the small intestine in this manner then a 'gallstone ileus' can develop when the stone impacts at the ileo-colic junction, causing small bowel obstruction. The classic features of this condition seen on a plain abdominal film are dilated loops of small bowel, gas in the biliary tree, and a calcified stone in the right iliac fossa. Gallstones are associated with carcinoma of the gallbladder, which is fortunately extremely rare as it is a very aggressive cancer.

Trans-abdominal ultrasound scanning is the investigation of choice for investigation of suspected gallstones, as it not only demonstrates stones but can also identify the thickened gallbladder wall of cholecystitis, and the dilated bile ducts of obstructive jaundice. Trans-abdominal ultrasound is poor at detecting CBD stones, and ERCP, MRCP, CT, EUS, or operative cholangiography may be necessary.

The treatment of choice for symptomatic gallstones is surgery, and cholecystectomy is one of the commonest elective procedures performed by general surgeons. Over the last 15 years laparoscopic cholecystectomy has become the accepted approach for the majority of patients, with less postoperative pain, and shorter hospital stay. Five per cent of laparoscopic procedures have to be converted to open chole-cystectomy for reasons such as technical failure, bleeding, and unclear anatomy, and this conversion rate decreases with the experience of the surgeon. Bile duct injury is the feared complication of cholecystectomy, and occurs in 0.1-0.2% of laparoscopic procedures - a figure which is not significantly different to historical data from open cholecystectomy.

One revolution that the laparoscopic era has brought to gallbladder surgery is the management of bile duct stones. In the days of open surgery 10% of patients were found to have CBD stones at operation, and these were managed by bile duct exploration as part of the same procedure. Laparoscopic exploration of the bile duct is a more complicated procedure, and management of duct stones has evolved accordingly, as has understanding of their natural history. Various systems have been proposed to predict patients who are at risk of having bile duct stones, and common indicators are: abnormal liver function tests, a history of obstructive jaundice, dilated CBD at ultrasound, a history of acute pancreatitis. Patients at risk of CBD stones should have imaging of their duct performed, either pre-operatively with one of the methods mentioned above, or during surgery by cholangiography or intra-operative ultrasound. Duct stones may be removed at ERCP or by operative duct exploration, both laparoscopically or open. It has become clear that the natural history of CBD stones is that the majority of small stones will pass spontaneously from a normal duct.

A variety of non-operative techniques have been tried in the management of gallstones, but none have become popular. Dissolution therapy with ursodeoxycholic acid was only suitable for limited patients, took up to 2 years to work, and stones recurred quickly once therapy was stopped. Extracorporeal shockwave lithotripsy (ESWL) has become very popular in the management of renal stones, but was associated with pain, pancreatitis, bile duct obstruction, and incomplete stone clearance when used on gallstones. Patients who are medically unfit for surgery may be stabilised by percutaneous drainage of the gallbladder (cholecystostomy), and stones may be extracted along the drainage tract - but recur rapidly as with dissolution therapy, and definitive surgical treatment is often preferable once their condition improves.

It is important to remember that 70-80% of gallstones are asymptomatic, and there is little evidence currently that intervention for asymptomatic stones is necessary or desirable. Gallstones found incidentally during investigations for other symptoms should be treated with caution. The fact that at least 5% of patients who undergo cholecystectomy have persistent symptoms post-operatively should serve as a warning that the presence of gallstones on ultrasound and vague abdominal symptoms does not necessarily mean that the two are connected.

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Get Rid of Gallstones Naturally

Get Rid of Gallstones Naturally

One of the main home remedies that you need to follow to prevent gallstones is a healthy lifestyle. You need to maintain a healthy body weight to prevent gallstones. The following are the best home remedies that will help you to treat and prevent gallstones.

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