Gallstones

Gallstones (Cholelithiasis)

Gallstones are hard, pebble-like substances that form in the gallbladder, a small organ located below the liver. The gallbladder stores bile, a fluid produced by the liver that helps break down fats during digestion. Gallstones can form when substances in bile, like cholesterol or bilirubin, harden into tiny crystals. Over time, these crystals can build up and grow together, hardening into gallstones.

Gallstones can vary in size, with some reaching the size of a golf ball. They may cause sharp, sudden pain in the upper right abdomen, which can radiate to the back or shoulder blade. This could signal a more serious condition requiring immediate medical attention.

What Are the Types of Gallstones?

Gallstones are typically classified into three types:

• Cholesterol Stones

  - These are the most common types of gallstones. They form when there is excess cholesterol in the bile. These stones tend to be yellow-green in colour.

• Pigment Stones

  - These stones are typically dark brown or black and form due to excessive bilirubin in the bile. This can happen due to liver cirrhosis, bile duct infections, or blood disorders.

• Mixed Stones

  - Mixed stones form when cholesterol or pigment gallstones mix with calcium deposits over time.

What Are the Signs and Symptoms of Gallstones?

When gallstones obstruct the bile ducts, bile can accumulate in the gallbladder, leading to a gallbladder attack, also known as biliary colic. Signs and symptoms typically arise after a fatty or oily meal, particularly at night, and may include:

• Persistent Abdominal Pain
• Nausea and Vomiting
• Fever and Chills
• Jaundice (Yellowing of the skin and eyes)
• Dark Urine or Pale Stools

What Causes Gallstones?

Several factors can contribute to the formation of gallstones, including:

• Excess Cholesterol - When the liver produces more cholesterol than the bile can dissolve, it can develop into cholesterol gallstones.
• Excess Bilirubin - Conditions like liver cirrhosis and biliary tract infections can increase bilirubin production, leading to gallstones.
• Insufficient Bile Acids (Bile Salts) - Bile acids help dissolve cholesterol in bile. A shortage can contribute to gallstone formation.
• Gallbladder Stasis (Cholestasis) - Reduced or halted blood flow can cause bile to become concentrated, increasing the risk of gallstones.
• Problems with Gallbladder Emptying - If the gallbladder does not empty properly, bile can become concentrated, leading to gallstone formation.

Who Is at Risk of Developing Gallstones?

Several factors increase the risk of developing gallstones, including:

• Older individuals, particularly after the age of 40
• Women, especially those with elevated oestrogen levels
• A family history of gallstones
• Obesity
• Rapid weight loss
• Medical conditions like diabetes, liver cirrhosis, or blood disorders

How Are Gallstones Diagnosed?

To diagnose gallstones, a doctor typically starts with a detailed medical history and physical examination. Diagnostic and imaging tests are often recommended, which may include:

• Blood tests - These tests assess liver function, bilirubin levels, blood count, and pancreatic enzymes, and check for signs of infection or inflammation.
• Endoscopic or Abdominal Ultrasound - An ultrasound device uses soundwaves to create detailed images of the bile ducts and pancreas, helping to detect gallstones.
• Endoscopic Retrograde Cholangiopancreatography (ERCP) - ERCP combines endoscopy and X-rays to visualise the bile ducts, identify gallstones, and perform treatments if needed.
• Magnetic Resonance Cholangiopancreatography (MRCP) - This type of MRI scan generates detailed images of the biliary and pancreatic ducts to detect gallstones.
• Gallbladder Radionuclide Scan - This test uses a safe radioactive material to produce pictures of the biliary tract to diagnose obstructions, such as gallstones.

What Are the Treatment Options for Gallstones?

Treatment for gallstones depends on the severity of symptoms and the type of gallstones. Common treatment options include:

• Medications

  - Oral bile acid pills can dissolve small cholesterol gallstones. However, the process of taking medications can be lengthy and not work for everyone.

• Surgery

  - Surgical removal of the gallbladder, known as cholecystectomy, is the most effective treatment for gallstones. There are two main approaches:

  • Laparoscopic Cholecystectomy

    - The surgeon uses small incisions and a camera to remove the gallbladder, which often results in faster recovery and fewer complications.

  • Open Cholecystectomy

    - The surgeon makes a larger incision to remove the gallbladder, typically reserved for complex cases such as severe infection, complicated anatomy, or prior abdominal surgery.

• Endoscopic Retrograde Cholangiopancreatography (ERCP)

  - This procedure is more invasive and is mainly used to remove gallstones stuck in the bile duct. It involves inserting an endoscope through the mouth and into the intestine to reach the bile duct.

• Sphincterotomy

  - This surgical procedure involves cutting the sphincter muscle between the bile duct and the duodenum to help gallstones pass into the small intestine.

Can Gallstones Go Away on Their Own?

Gallstones can sometimes go away on their own, especially if they are not causing symptoms. However, they often persist or can lead to complications if left untreated. Gallbladder removal is the definitive treatment for persistent gallstone-related issues.

What Are the Possible Complications of Having Gallstones?

Gallstones can lead to several complications if left untreated. Some possible complications include:

• Cholecystitis

  - An inflammation of the gallbladder, often caused by a gallstone blocking the cystic duct.

• Acute Pancreatitis

  - An inflammation of the pancreas that often occurs when a gallstone blocks the bile duct.

• Cholangitis

  - An infection of the bile ducts, often caused by a gallstone blocking the common bile duct, allowing bacteria to grow.

• Gallbladder Perforation

  - A rare but serious complication where the gallbladder wall ruptures, releasing bile and causing severe infection and inflammation in the abdomen.

• Gallbladder Cancer

  - A rare type of cancer that begins in the gallbladder and is difficult to detect, especially in its early stages.

• Septicaemia

  - A life-threatening blood infection that can occur as a result of cholangitis and gallbladder perforation.

• Gallstone Ileus

  - This rare condition occurs when a large gallstone blocks the intestines.

Meet Our Gallstone Specialist

Dr Wong Jen San

Consultant Hepatobiliary & Pancreatic SurgeonMBChB (UK), MMed (S’pore), Msc (S’pore), FRCS (Edin), FAMS

As a founding member of the Hepatopancreatobiliary Association Singapore, Dr Wong Jen San specialises in the treatment of all gallbladder conditions, including gallstones. He has extensive international experience, having obtained fellowships in the UK and Japan. His years of practice have established him as a trusted and respected doctor in gallstone treatment in Singapore, particularly in minimally invasive (laparoscopic) surgery.