Gallbladder Stone

Overview

Gallstones are stones which are formed in the gallbladder.

The gallbladder is a small, pear-shaped organ located below the liver in the right upper abdomen. The gallbladder stores a digestive fluid called bile that is released into the small intestines to aid digestion. Bile is produced by the liver.

Bile contains many components, including cholesterol, bile pigments and bile salt. Gallstones are formed when cholesterol or bile pigments precipitate out of bile as small crystals. As these crystals enlarge, they form gallstones. Gallstones range in size from as small as a grain of sand to as large as an almond seed. The number of stones may also vary from person to person.

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Symptoms

Majority of people with gallstones have no symptoms. However, when symptoms appear, they can range from mild to severe:

– Bloating or sensation of indigestion or fullness

– Mild pain felt in the right upper abdomen or “gastric” area

– Frequent belching

A unique feature of gallstone symptoms is that symptoms tend to occur after a meal, especially after eating oily or fried food like curry or laksa.

 

Gallbladder Attack

This occurs when the stone blocks the outlet of the gallbladder. When this happens, this person will complain of severe pain lasting 30 minutes to several hours. This person will usually experience cold sweats and nausea. This is called biliary colic. The attack may stop spontaneously should the gallstone fall back and no longer block the outlet. However, if the blockage persists, the patient may develop acute infection of the gallbladder (acute cholecystitis).

Although gallstones are usually not life-threatening, there are situations where gallstones can cause complications that may lead to severe illness and even death. Such complications include acute pancreatitis, acute cholecystitis, and acute cholangitis.

When to Seek Treatment

If a person has any of the symptoms as described above, he or she should consider consulting a doctor. This is because once symptoms arise, they tend to recur or become worse.

Diagnosis

The doctor will take a detailed history. This is because gallstone symptoms may sometimes overlap with symptoms of stomach problems or reflux problems.

To confirm the diagnosis of gallstones, the doctor will usually order an ultrasound. This is a simple inexpensive non-invasive test, but very accurate in diagnosing the presence of gallstones.

Treatment

If the gallstones do not cause any symptoms, they can be left alone.

On the other hand, if the doctor establishes that the symptoms are indeed due to gallstones, the doctor will advise surgery to remove the gallbladder. This operation is called cholecystectomy. This surgery is one of the most common operations performed on adults in the world.

There are three methods to perform this operation.

1. Laparoscopic Cholecystectomy (Keyhole Surgery)

The gallbladder is removed through 4 small cuts which  will be made on the abdominal area. These cuts range in size from 5mm to 1cm. Tiny clips are used to seal the blood vessels of the gallbladder and the cystic duct that connects the gallbladder to the bile duct. The gallbladder together with the stones will then be extracted upon completion of the operation.

2. Single Incision Laparoscopic Surgery (SILS) Cholecystectomy

Also called a “Scar-less operation”, the gallbladder is removed through 1 single wound about 2cm on the naval rather than 4 small wounds in laparoscopic surgery.

Some studies from the USA found that this method may have a higher surgical complication.

[reference: “Single Incision Laparoscopic Cholecystectomy Is Associated With a Higher Bile Duct Injury Rate: A Review and a Word of Caution.” Annals of Surgery 2012; 256: 1-6]

3. Open Cholecystectomy

This is the traditional method of surgery where the gallbladder is removed through a large incision of about 10-12cm long made along the right upper abdomen. This method may have to be performed for special circumstances such as a severely inflamed gallbladder, infection, or scarring from previous operations.

Today, nearly all gallbladder removal surgery is performed laparoscopically. It is a minimally invasive operation with the advantages of less pain, faster recovery, and earlier return to normal activities. The hospital stay is also shorter. Our patients typically stay for only one night.

Causes

The causes of gallstone formation are multi-factorial. However, the effect of these causes basically lead to a loss of balance of the different components within the bile. This consequently results in some of these components crystallizing out. Such crystals become the seed for the formation of stones.

Risk Factors

Some people are more prone to having gallstones. These groups are easily remembered as the 4Fs

Female:

Gallstones are more common in women than men, in particular the middle-aged females. The incidence of gallstones in women is 2-3 times that in men.

Forties:

It is more common amongst people who are middle-age or older. Some statistics mentioned that 3 out of every 10 persons above the age of 60 years old may have gallstones.

Fat:

It is more common amongst people who are overweight

Fertile:

It is more common amongst women who has previously delivered a child

[reference: “Epidemiology of Gallbladder Disease: Cholelithiasis and Cancer.” Gut Liver 2012; 6(2): 172-187]

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FAQs

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!

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