Cholelithiasis (AKA Gallstones)

Cholelithiasis, or ‘gallstones’, affect around 10 percent of the population. That’s a fair whack of people. When I was a student, we were given the mnemonic Fat, Fair, Female, Fertile and Forty as being the catchy 5F’s to remind us of the ‘typical’ gallstone sufferer. Of course, like all catchy mnemonics it isn’t quite true as 10 percent of men also have gallstone problems.

Unsure where your gall bladder is hiding? It is found under your lower ribs on the right side of your body and is attached to the underside of your liver and is involved with digestion. In its natural healthy state it is like a hollow sausage attached by a tube (the bile duct) to your “stomach”. It is when it gets gallstones inside it that you begin to get a problem.

So where do these gallstones come from? Well, 80 percent of them are made of our old friend Cholesterol, or Cholesterol mixed with pigment, that’s why you can get gallstones in such pretty colors, though I am yet to see any made into a necklace, but it could catch on, I suppose.

The Cholesterol stays in solution until something happens to slow down the emptying of the gall bladder, or thicken the solution, such as happens during fasting or dehydration. This results in what we call biliary “sludge” which then hardens and turns into gallstones. Another good reason to drink more water. Beer is not the same as water, sorry.

Factors which increase the likelihood of developing gallstones include increasing age, obesity, a diet high in animal fats and certain medical conditions such as diabetes. Oh yes, pregnancy also increases the incidence. (With all these problems that can happen with procreation, it is a wonder the human race has got this far!)
The management of gallstones has also changed dramatically over the past 20 years because of three main factors. The first was the development of Ultrasound visualization. At last we had a way of diagnosing gallstones by actually seeing them in situ. Not only could we now “see” the gallstones, but we could tell if they really were the cause of the pain by being able to pick out the inflammation in the gall bladder wall.

The second development was ERCP (you know how we love acronyms in medicine) which stands for Endoscopic Retrograde Cholangio-Pancreatography. At the end of the operating telescope (the Endoscope) the surgeon can sneak into the bile duct and scoop out stones that are blocking the duct which have been causing jaundice. This is one of the common causes of jaundice - but not the only cause.

The third development was Laparoscopic Cholecystectomy and was pioneered in 1987 by a French surgical team. Instead of practically sawing you in half to get at the gall bladder, hiding under the liver, this is a much less invasive method, where the operating laparoscope is inserted through a small incision in the abdominal wall, and the surgeon does the job under the direct vision. While this results in less trauma, shorter hospitalization and quicker recovery, it is not always successful, as if there has been much recurrent inflammation, the gall bladder can be very difficult to extract and the operation may have to be converted to the older “open” method.

The principal presenting symptom in cholelithiasis is pain, but some people with cholelithiasis have no symptoms at all, while others may have severe abdominal pain, nausea and vomiting, and complete blockage that may pose the risk of infection. Cholelithiasis can lead to cholecystitis, which is inflammation of the gallbladder. Acute gallstone attacks may be managed with intravenous medications, but chronic (long-standing) cholelithiasis is best treated by surgical removal of the gallbladder.

It is also important to remember that gallstones can be found incidentally, and if they are causing no problems, the answer is simply to leave them alone. The chances of developing symptoms over 20 years are about 18 percent the good books tell me, so with an 82 percent chance of getting off with nothing, who is going to volunteer for an operation? What “gall” to even suggest it!