MEN'S HEALTH MATTERS:Are gallstones dangerous?
Q I’m a 44-year-old man and have had intermittent pains in my upper abdomen for the past few months. My GP referred me for an ultrasound examination and the radiologist said that I had gallstones in my gallbladder. Can you tell me what gallstones are, how they cause my symptoms and can they be dangerous?
AThe best way to describe and explain gallstones is first to explain the nature and function of the bile and its reservoir, the gallbladder. All of us manufacture and secrete bile from the liver cells. It is collected in tiny tubes in the liver called bile ducts.
Bile then flows to a tube outside of the liver – the common bile duct – and passes into the gallbladder where the bile is stored. Bile contains acids essential for digestion (emulsification) of fats; the bile breaks down the fats to smaller products allowing other enzymes to further digest them.
Bile is composed mainly of water, cholesterol, bile salts, proteins, and bilirubin (the latter is a waste product), and these substances are balanced in proportion to keep the bile in a liquid form.
The gallbladder is a pear-shaped sac which holds the liquid bile. The gallbladder contracts, usually after eating, and pushes the bile into a tube (the common bile duct) that carries it to the small intestine, where it helps with digestion.
The liquid state of bile can change – usually due to an imbalance between the bile salts and cholesterol – and may lead to the bile becoming more solid; this can result in the development of small, pebble- like gritty deposits and eventually stones. Small stones may form a focus point for the development of large stones, occasionally to the size of a golf-ball.
Excess cholesterol can cause the bile to harden and stones may develop (this is the most frequent cause of gallstones in the Western world). Too much bilirubin can also cause stone precipitation (more frequent in Eastern populations).
Stones can also develop from liquid bile becoming gritty within a static gallbladder, for example, when a sick patient fasts for a long period where the gallbladder does not contract often. Some medications may also result in a lazy gallbladder.
Several factors can contribute to the formation of gallstones, particularly cholesterol stones, including the sex of the patient – women are twice as likely as men to develop gallstones (oestrogen from pregnancy, hormone replacement therapy and birth control pills appear to increase cholesterol levels in bile); age (gallstones are more common in elderly people); family history (there is a weak genetic link to gallstones); obesity and high fat/cholesterol diets (probably from low bile salts and excess cholesterol in the bile; high fats also reduce the contractions of the gallbladder); and certain drugs may increase the amount of cholesterol secreted into bile.
Most people with gallstones do not have any symptoms – their so-called “silent” stones need no medical attention – while about one-third of individuals display symptoms.
Gallstones are often mobile and can move to block the outflow from the gallbladder – stones become lodged in the neck of the gallbladder resulting in a colicky pain. The pain can be intense in the right upper abdomen, building up to a severe point that may last from minutes to hours.
These pains do not come from a congested liver but rather from stones blocking the gallbladder outlet, causing spasms of severe pain and gallbladder distension and inflammation. Stones may lodge in any part of the ducts that carry bile from the liver to the small intestine.
A stone that passes to the lower end of the bile duct may also temporarily block the pancreatic duct leading to inflammation of the pancreatic gland (referred to as acute pancreatitis).
If any of the bile ducts remain blocked for a significant period of time, the bile building up in the bile duct can spill over into the bloodstream and the patient may become jaundiced. This can be very dangerous, and warning signs of a serious problem are fever, jaundice – yellow skin or whites of eyes, pale stools and dark urine – and persistent pains. Pains of this nature and either persistent fever or jaundice needs rapid medical attention.
Fortunately, however, the majority of gallstones do not cause any symptoms. The most common symptoms of simple gallstones is pain under the right ribcage or occasionally in the right shoulder resulting from an inflamed gallbladder.
The majority of cases do not cause any complications and the gallbladder can be removed with keyhole surgery if necessary.
This weekly column is edited by Thomas Lynch, consultant urological surgeon, St James’s Hospital, Dublin, with a contribution from Prof Dermot O’Toole, consultant gastroenterologist/pancreatologist, St James’s Hospital, Dublin
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