Gallstones can be painless and cause no health problems (i.e. asymptomatic). The chance of complications arising from asymptomatic stones is one to two per cent each year. Complications like cholecystitis, obstructive jaundice, cholangitis or pancreatitis may arise.
Gallstones develop as a result of an imbalance in the components of bile. In a normal person, cholesterol in the bile is prevented from forming stones by bile acids and proteins secreted in the bile.
A diet rich in cholesterol, female gender, obesity, multiparity, genetic factors, old age, total parenteral nutrition, poor contraction of the gallbladder and hemolytic anemias can predispose patients to gallstone formation by causing an upset in the balance. Cholesterol crystals form and these enlarge to become "sludge " and later stones.
Symptoms like belching, fullness after meals, vague "indigestion" are not typical gallstone symptoms. It is important to identify clearly the patient's symptoms because operations to remove the gallbladder may not result in a cure if the symptoms are not due to stone. Typical biliary colic due to gallstones is a persistent severe pain in the upper abdomen, occurring usually after a meal and lasting several hours. Fever occurs when there is cholecystitis, or cholangitis.
Other conditions may mimic gallstone disease and include peptic ulcer disease, liver disease, irritable bowel syndrome and the occasional heart attack.
Gallstones that do not cause any symptoms are best left alone as the chance for developing pain and other complications is low.
The treatment of gallstones causing symptoms is cholecystectomy. This is usually performed via laparoscopy which leaves small scars resulting in less pain and a fast recovery after a few days. Sometimes technical difficulties result in conversion to "open " cholecystectomy to ensure a safe operation and avoid injury of the biliary tree.
Gallstones which have migrated into the bile duct can be removed by Endoscopic Retrograde Cholangio-Pancreatography (ERCP) in 90 to 95 per cent of the time. After an incision of the papilla at ERCP, small stones can be removed. Big stones can be crushed into smaller pieces before removal. When stones are too big to be removed, a plastic stent can be inserted to relieve the obstruction. This is especially useful when the patient is frail, is not fit for surgery or refuses surgery.
Oral bile acid (ursodeoxycholic acid) therapy is available to dissolve gallstones. However, only cholesterol stones can be treated and there are several limitations. The duration of treatment is six months to two years and stones tend to reform in the gallbladder after treatment is stopped.
Post-cholecystectomy Syndrome
Some patients continue to have symptoms after surgery for gallstones. This may be due to residual stones in the bile duct not detected before the operation. Other conditions which cause abdominal pain may co-exist with gallstones, such as irritable bowel syndrome or non-ulcer dyspepsia which persist following the successful removal of gallstones.
In conclusion, with an " ageing " population, gallstone prevalence will increase and a clear understanding of the natural history, symptoms, complications and indications for treatment will provide appropriate management of the condition.