Frequently Asked Questions regarding Gallstones
A gallstone is simply a stone that is formed in the gallbladder. The gallbladder is a pear-shaped organ attached to the under surface of the liver on the right side of your body. The gallbladder contains bile, a liquid made up of water, proteins, cholesterol, bile salts and bile pigments (also called bilirubin). Gallstones are formed when some of these components in the bile increase in quantity to become out of proper proportion to each other. These components will then crystallise out and form sediments. Over time, these can enlarge to become stones. The size of the stones can range from as small as a grain of sand, to actual pebbles, usually with a diameter of between 5mm to 1cm.
Another reason for the formation of gallstones is when the gallbladder fails to empty completely. This allows the bile within it to stagnate, and this predisposes to an imbalance of the components that are in the bile.
The composition of the stone is based on which component in the bile has crystallized out to become the predominant make-up of the stone matrix. Cholesterol is the component that most often increases and precipitates out as crystals forming cholesterol stone. The next culprit is bile pigment, forming pigment stones. When the composition of the stone is a mixture of components, it is called a mixed stone.
Women are twice as likely as men to develop gallstones, especially in ladies who have had children. The main reason is the female hormone, oestrogen. Excess oestrogen from pregnancy, hormone replacement therapy, and birth control pills can potentially increase cholesterol levels in bile and decrease gallbladder movement, which then lead to gallstones.
Medical students are often taught the 4 “Fs” when they discuss who are at risk of gallstones. The 4”Fs” are Fat, Female, Fertile and Forty. Hence, besides people who are obese and females, especially those who have had children, those who are forty or older also have an increased risk of gallstones.
The classical symptoms are abdominal discomfort, typically after a heavy meal or after taking fatty food. This discomfort will be felt in the upper abdomen, either in the midline, or beneath the rib-cage on the right side. The discomfort can range from just a sensation of indigestion or bloating, to actual intermittent colicky pain. Sometimes, the pain may radiate to the back over the right shoulder.
Fortunately, for most people with gallstones, the gallstones are actually silent, as in the patients do not complain of any symptoms.
The best test to diagnose gallstones is the ultrasound. It is non-invasive and has no radiation risk. It is quite inexpensive too.
Yes, but such complications are rare. The gallstone may block up the duct of the gallbladder and cause infection of the gallbladder, also known as acute cholecystitis. A severe form of infection may result in gangrene of the gallbladder. Sometimes the gallstone may slip into the common bile duct and cause obstruction of the bile duct, causing jaundice. If the obstructed ducts get infected, also called cholangitis, this may lead to septicaemia and death.
It depends on whether the patient has any of the symptoms described above. If the patient has no symptoms, the gallstones may be safely left alone, and no treatment is required. If the patient is symptomatic, we would arrange for an elective operation to remove the gallbladder. This operation should be done within 3 months of diagnosis. If the patient develops one of the complications like gallbladder infection (acute cholecystitis), the patient should seek urgent medical attention. Once acute cholecystitis is confirmed, early surgery during the same admission should be performed so as to reduce the risk of another attack. Similarly, if the patient suffers acute pancreatitis (acute inflammation of the pancreas) as a result of the gallstones, early surgery is advised.
In today’s context, the standard operation for the removal of the gallbladder is via laparoscopic technique. This operation is called laparoscopic cholecystectomy. This entails performing the operation through 4 small punctures. For patients who request for a better cosmetic outcome, the surgery may also be performed through a single puncture made in the umbilicus. This is also called “scarless” surgery as the scar is well hidden within the umbilicus.
Following a laparoscopic removal of the gallbladder, most patients usually stay for one night. Most of them can return to work within a week. They can also resume most of their social activities in a week’s time.
The largest gallstone reported in medical literature was one of 6.29 kg (13 lb 14 oz) removed from an 80-year-old woman by Dr Humphrey Arthure (UK)(1905–96) at Charing Cross Hospital, London, UK, on 29 December 1952. That’s equivalent to the weight of a bowling ball!