Gallstones: what they are, causes and treatments

• Gallstones form due to the accumulation of substances in the gallbladder because bile cannot dissolve them.
• Complications of gallstones are diverse, but one of the most dangerous is biliary peritonitis which can cause very serious consequences.
• The only solution to relieve symptomatic gallstone problems is a cholecystectomy surgery.

Gallstones, or cholelithiasis, are small stones that form in the gallbladder due to a high concentration of substances, cholesterol or bilirubin, which can lead to inflammation of this organ, obstruction of the outflow ducts or bile ducts, and in some cases the rupture of the gallbladder walls, which can have serious consequences.

Despite this last statement, cases of biliary peritonitis (rupture of the gallbladder) are rare, as doctors diagnose gallstones early enough to solve and avoid potential problems by performing a cholecystectomy surgery.

It is also important to mention that the presence of gallstones does not always lead to a symptomatic affectation of the patient, as in many cases people suffering from gallstones do not suffer any symptoms and if they are detected it is through abdominal X-rays, ultrasound scans or other types of tests related to pathologies other than cholelithiasis or gallstone formation.

Gallstones form due to the accumulation of substances in the gallbladder that are so concentrated that bile is unable to dissolve them. These gallstones can be:

• Pigmentary gallstones: These are stones that form due to the breakdown of red blood cells due to associated pathologies, the excessive production of bilirubin as a result of this breakdown and the inability of the bile to dissolve it completely, causing the stones to form.
• Cholesterol gallstones: These stones are due to the gallbladder's inability to dilute the cholesterol excreted by the liver, resulting in the formation of stones due to accumulation of cholesterol.

There are risk factors that lead to a higher incidence of gallstones. Some of them are listed below:

• Women suffer more from gallstones than men.
• Symptoms of gallstones usually appear after the age of 40, although they can occur earlier.
• Being overweight, a sedentary lifestyle and poor diet are a major risk factor in the development of gallstones.
• Diabetes
• Cirrhosis of the liver or infections of the bile ducts cause pigmentary (bilirubin) gallstones.

Symptomatic gallstones are the least common, i.e. people who have gallstones in their gallbladder do not usually suffer from symptoms, other than perhaps occasional pain after large meals at specific times of the year.

But in other cases gallstones do cause symptoms, which are quite annoying and problematic. Among these symptoms we can highlight:

• Pain in the upper right side of the abdomen: This is the most common symptom par excellence. It is sometimes accompanied by nausea and vomiting.
• Biliary dyspepsia: This is intolerance to fatty foods, flatulence, bloating in the abdomen and vomiting. For relief, the best option is cholecystectomy (removal of the gallbladder).
• Cholecystitis: Cholecystitis is an inflammation of the walls of the gallbladder due to obstruction of the bile ducts by gallstones that prevent them from emptying. It can be acute, with occasional inflammation, or chronic if the associated discomfort occurs periodically. In cases where gallstones cause acute cholecystitis, emergency surgery will be necessary.
• Biliary colic: This occurs when a gallstone blocks one of the bile ducts, producing the following symptoms:
• Pain in the upper right area of the abdomen, which usually subsides with the intake of analgesic medication or in other cases, subsides spontaneously.
• These are usually associated with inflammation of the gallbladder due to obstruction of the bile ducts.
• Jaundice (change of colour of the skin and eyes to a yellowish hue)
• Vomiting and nausea.

In cases where patients suffer from multiple gallstones or chronic cholecystitis due to gallstones, it is advisable to have the gallbladder removed to avoid the discomfort of frequent symptoms and to avoid the possibility of complications such as acute cholecystitis, pancreatitis and even biliary peritonitis, the most serious and dangerous complication of gallstones.

Treatment of gallstones is surgical in almost all cases. In patients where surgery is not indicated, it is usually due to associated medical problems that preclude intervention, although the chances of successful non-surgical treatment are virtually non-existent.

Gallbladder removal surgery can be performed using different techniques and surgical approaches, although the goal of the surgery is the same, the removal of the gallbladder for symptom relief.

Below is a list of the different types of gallstone surgery available.

Cholecystectomy by laparoscopy

The peculiarity of this surgery to solve the problems caused by gallstones is that it is performed using minimally invasive surgery, laparoscopy. The procedure consists of removing the gallbladder without making a large incision in the abdomen, which is common in open cholecystectomy.

To do this, a laparoscope is used, an instrument consisting of a tiny camera with a light at its end connected via fibre optics to a monitor, where the surgeon can see live what the camera is recording inside the patient.

The main advantage of performing cholecystectomy by laparoscopy is that post-operative recovery is much less than in cases of open surgery, as wound care must be less intense and the wound heals more easily.

The following steps are followed to perform the laparoscopic gallbladder removal operation:

• Once the patient is under anaesthesia, the surgeon makes three small incisions in the abdomen. Through one of these incisions, the surgeon introduces carbon dioxide, which allows him to enlarge the abdominal cavity and thus make it easier to see and manoeuvre.
• He then inserts the laparoscope through one of the incisions to view the inside of the abdomen and uses the remaining incisions for the surgical tools needed to remove the gallbladder.
• Using the vision provided by the laparoscope, the surgeon carefully removes the gallbladder and extracts it through one of the abdominal incisions, suturing the bile ducts that connect the gallbladder to the small intestine and liver.
• Once the removal is complete, the incisions are sutured and the patient is awakened from anaesthesia.

Open cholecystectomy

This is conventional surgery for the removal of the gallbladder. It pursues the same objective as laparoscopic cholecystectomy, although it is performed using an open procedure. The main difference is that in this case, the scar and recovery time will be longer due to the size of the surgical wound, which will require specific care.