Cholelithiasis. Causes, symptoms and treatment

• Cholelithiasis is the formation of gallstones, also called stones, in the gallbladder.
• The causes of cholelithiasis can vary, but are mainly due to excess fat consumption.
• The symptoms of cholelithiasis continue to worsen over time, so the only definitive treatment is a gallbladder removal operation or cholecystectomy.

Cholelithiasis, or gallstones, is one of the most common digestive system problems. It consists of the formation of gallstones in the gallbladder, a pear-shaped organ attached to the liver, or in the bile ducts that connect it to the other organs of the digestive system.

The function of the gallbladder is the storage of bile until the daily food intake takes place. At this point, the gallbladder sends bile through the bile ducts to the small intestine, where it aids in digestion. 

The need for bile is especially important when large amounts of high-fat foods have been eaten, as they are more difficult to digest and require more effort from our system.

The size of these stones can vary from a grain of sand to a golf ball in the most extreme cases.

Cholelithiasis can be of two types depending on the main compound:

• Cholesterol gallstones. This is the most common type of cholelithiasis and, despite what you may think, is not related to blood cholesterol levels. It occurs because the cholesterol excreted by the liver is greater than the bile's capacity to dissolve it, favouring the formation of gallstones.
• Bilirubin gallstones (pigment stones). This type of cholelithiasis forms when red blood cells break down, producing excess bilirubin due to some kind of medical problem causing an inability of the bile to dissolve it, forming what we know as pigment gallstones.
• Another type of gallstones that can form may be due to gallbladder emptying problems, because if the gallbladder is not completely emptied often enough, the bile can become very concentrated and can lead to the formation of cholelithiasis (gallstones).

The causes that favour the formation of cholelithiasis are varied and in most cases, the appearance of gallstones is due to a combination of several of these risk factors. The following is a list of some of the factors related to the development of gallstones:

• Being a woman. Women are much more likely to suffer from cholelithiasis than men.
• Being over 40 years of age. In the vast majority of cases, in both men and women, symptomatic cases of cholelithiasis occur in people over the age of 40.
• Overweight. Being overweight and sedentary are two factors that in general are not good for health, being a very important factor in the appearance of gallstones due to bad eating habits that lead to this state (very fatty foods, intestinal overexertion, etc.).
• Hereditary factors. It has been found that in some cases, people whose families had previous cases of cholelithiasis are more likely to suffer from this problem.
• Diabetes. People with diabetes should lead a healthy life to avoid any problems in general.
• Liver cirrhosis or bile duct infections. They cause an increase in bilirubin forming pigment stones.

It is important to note that cholelithiasis is not always symptomatic, being in many cases discovered through tests for other problems such as X-rays, abdominal surgery or other medical procedures.

However, in other cases the symptoms of cholelithiasis are present and can cause severe discomfort and even major medical problems such as biliary peritonitis. Among the symptoms that can be suffered due to cholelithiasis, depending on the problem that causes them we can talk about:

• Biliary dyspepsia: The symptoms of biliary cholelithiasis include intolerance to fatty foods, flatulence, abdominal swelling and even vomiting.
• Biliary colic: Biliary colic is felt in the upper right side of the abdomen and occurs when one of the gallstones blocks one of the bile ducts. In these cases the patient presents with the following symptoms:
  • Pain in the right upper abdomen until it subsides spontaneously or by taking painkillers or spasmolytics.
  • Blockage of the bile ducts by a gallstone is associated with inflammation of the gallbladder (cholecystitis).
  • Although rare, biliary colic is sometimes accompanied by fever and a yellowing of the skin and eyes called jaundice. 
  • Finally, vomiting and nausea are also possible.
• Acute or chronic cholecystitis: Cholecystitis, or inflammation of the gallbladder, is mainly caused by obstruction of the bile ducts, as previously mentioned. Cholelithiasis can cause acute cholecystitis, if it occurs on a one-off basis, or chronic if it involves a periodic occurrence of cholecystitis-related problems. In cases where cholecystitis causes acute inflammation of the gallbladder, surgery will be necessary.

It is important to mention that in many cases the symptoms caused by cholelithiasis are reduced to pain in the right upper abdomen, without vomiting or nausea. However, in cases of chronic cholecystitis or multiple cholelithiasis, even if asymptomatic, it is advisable to remove the gallbladder by cholecystectomy to avoid any possible serious problems in the future, such as the aforementioned biliary peritonitis.

Complications of cholelithiasis

As previously mentioned, cholelithiasis and its symptoms can remain mute and uncomplicated for a long time, in many cases never being diagnosed or treated even though they are there.

When the first symptoms appear, they will persist over time, either continuously or intermittently, gradually worsening and can considerably reduce the quality of life, especially in the case of older people who may have other associated medical problems.

The ultimate complication that inevitably requires cholecystectomy is acute inflammation of the gallbladder due to complete obstruction of the ducts connecting the gallbladder to the small intestine. If action is not taken soon, the gallbladder may rupture, causing biliary peritonitis.

After the initial suspicion of gallstones, laboratory tests such as blood tests can be performed. In these routine blood tests, it is difficult to be able to determine with diagnostic certainty the presence or not of stones inside the gallbladder, but it does allow the specialist or family doctor to rule out other pathologies that may cause pain in this region of the abdomen.

Imaging tests are very important in the diagnosis of gallstones. Of these, the most sensitive, specific and easily accessible is abdominal ultrasound, with a success rate of over 95% in stones larger than 2mm. The use of CT or magnetic resonance imaging (MRI) is usually postponed to diagnostic doubts and preoperative studies in patients with risk factors.

If you have a diagnosis of cholelithiasis and need surgery to solve the problem, you can request a free surgical assessment consultation with one of our doctors, specialists in General and Digestive Surgery.

If you have a diagnosis of cholelithiasis and In the case of gallstones detected in the gallbladder through an X-ray or ultrasound and that do not present symptoms, no treatment is required, it will only be necessary to maintain a watchful and attentive attitude to detect the appearance of symptoms of cholelithiasis if they were to occur.

In most of these cases, patients will never require a cholecystectomy operation. 

On the other hand, symptomatic cholelithiasis does require treatment. This treatment can be surgical, such as open or laparoscopic cholecystectomy, or non-surgical by means of medication:

• Medications to dissolve cholelithiasis. This treatment is done orally and the success rate is very low.
• Cholecystectomy (gallbladder removal). The main treatment of choice for the relief of symptoms of cholelithiasis is the cholecystectomy operation. This surgery involves the careful removal of the gallbladder, thus eliminating pain and avoiding the possibility of serious complications such as biliary peritonitis, mentioned several times in this article. This surgical intervention can be performed using different techniques or approaches, such as traditional open surgery, laparoscopic surgery or transvaginal gallbladder removal.

Laparoscopic gallbladder removal

The laparoscopic gallbladder surgery for the relief of symptoms of complications of cholelithiasis involves the introduction into the abdominal cavity of a mini-camera that has a light at its distal end and is connected by fibre optics to a monitor where the surgeon can view the inside of the patient.

The differentiating feature of this technique over open surgery is that the doctor only needs 3 mini-incisions in the abdominal area to insert the camera and surgical instruments to remove the gallbladder. This has the advantage of avoiding the scarring of open surgery and reducing the postoperative recovery time and the chances of complications, as wound care is much simpler.

Open cholecystectomy

Cholecystectomy involves the removal of the gallbladder by conventional surgery. The final results are just as good as in the case of gallbladder removal, with the only difference being that the scar that remains is much more visible and postoperative recovery takes a little longer.

Gallbladder removal via transumbilical or transvaginal route

This technique is also performed laparoscopically, with the main difference being that in the case of transumbilical surgery only an incision is made at the bottom of the navel and in transvaginal surgery the gallbladder is removed from the bottom of the vagina. In both cases, the scars are invisible after recovery.