Gallstones occur commonly. The incidence is approximate one million cases per year. Approximately 25 million cases are present any particular time. All gallstones may become calcified. The cholesterol stone is the most common. It is usually larger (2.5 cm) and may be present in either solitary or multiple numbers.

Approximately 10 percent of the American population have gallstones. In the past, it was extremely common for patients with gallstones to have immediate gallbladder surgery. However, with the development of ultrasound examinations of the biliary tract, it has been shown that many patients do not have any symptoms even when gallstones are present. Gallstones, in this situation, should be observed. The patient should have further evaluation when symptoms develop.

If a patient develops symptomatic gallstones, there may be pain in the right upper abdomen which may (or may not) radiate to the right shoulder or to the right scapula (shoulder blade). Also, darkened urine and whitish stools are characteristic of an acute attack of gallstones. Gallstones may migrate into the common bile duct causing a condition called choledocholithiasis (common bile duct stones). If common duct stones are identified, an ERCP (Endoscopic Retrograde Cholangio Pancreatogram) is usually performed by the gastroenterologist before surgery. The danger of choledocholithiasis (gallstones in the common bile duct) is the development of infection in the bile ducts and gallstone pancreatitis.

Risk factors for cholesterol gallstones include:

	Ethnic origin: Pima Indians have an especially high incidence of gallstones. This is particularly true in women. In these patients there is an association with saturation of cholesterol.
	Age: increasing age is associated with increasing incidence of gallstones.
	Pregnancy.
	Estrogen use: birth control pills as well as estrogen replacement therapy induces gallbladder stasis and changes decomposition of lipids within bile acids. Both of these may then predisposed towards forming gallstones.
	Obesity
	Diabetes mellitus.
	Types 1 and 4 hyperlipidemia.
	Cystic fibrosis.
	Pancreatic insufficiency: absorption of bile salts or an increase in lithogenicity of bile salts. This predisposes to gallstone formation.
	Clofibrate: this medication inhibits cholesterol synthesis. Therefore, it increases bile salt secretion of cholesterol. This subsequently will increase in the lithogenicity of bile acids promoting gallstone formation.
	Somatostatin: somatostatin acts to inhibit gallbladder contraction. This subsequently induces gallbladder " stasis " which then promotes gallstone formation.
	Diet: diets high in calories, refined carbohydrates and high in polyunsaturated fats will promote gallstone formation.
	Rapid weight loss.
	Family history: patients with a history of first-degree relatives with gallstones have an increased incidence of gallstone formation.
	Spinal injury.
	Total parenteral nutrition.
	Truncal vagotomy (a procedure used to treat peptic ulcers in the past).

Pigment stones: these are usually black stones but many be brown as well. The stones are usually calcified. The calcification is usually centrally located.

The stones are associated with hemolysis, cirrhosis and elderly patients. Thirty percent of stones in United States are pigmented stones. These are usually black stones.

Risk factors for pigmented stones:

	Age: present usually in patients who are the 6th to 7th decade of life.
	Infection with Clonorchis sinensis.
	Infection with Ascaris lumbricoides.
	Biliary stasis.
	Sphincter of Oddi spasm (usually associated with opiate use).
	E. Coli infections. E. Coli infection reduces the pH of the bile ducts and allows for gallstone formation.

Clinical presentation:

One-third of patients with gallstones have no symptoms. Approximately one-third experience mild symptoms. 1/5 of patients have serious complications associated with a gallstone disease. These complications consist of the following:

	Acute cholecystitis.
	Sepsis (infection of the blood due to bacteria derived from the bile ducts).
	Cholangitis (infection in the common bile duct).
	Peritonitis (infection in the peritoneal cavity).
	Fistulous formation (abnormal tubular connections between various parts of the GI tract).
	Gallstone ileus.

Biliary colic is the term used to describe pain associated with symptomatic gallstones. This pain usually occurs after heavy meals. It is usually located in the right upper quadrant and may radiate to the epigastrium, back and shoulder blades. The pain may last for 1 to 6 hours. It may be mild or severe. Most patients experience nausea and vomiting.

Other conditions that may present in a similar fashion include the following:

	Myocardial infarct.
	Ruptured aortic aneurysm.
	Perforated peptic ulcer.
	Pneumonia.
	Pneumothorax.
	Pleurisy.
	Intestinal obstruction.
	Intestinal ischemia.
	Pancreatitis.
	Renal colic.

Evaluation of this condition includes an ultrasound, liver function tests, amylase, lipase, complete blood count, urinalysis and electrolytes. An oral cholecystogram helps to visualize the gallbladder. However, it is not as sensitive as ultrasound. CT scan may also be used in patients with difficult or complicated cases.

Management

If the patient symptoms are uncomplicated pain control, morphine sulfate, etc. may be the most appropriate avenue. Laparoscopic cholecystectomy is then performed in order to remove the stones.

Other therapeutic options include:

	Percutaneous Choleycystolithotomy (draining gallbladder via a tube). This is a new procedure is usually not utilized commonly.
	ECSWL: (extracorporeal shock wave lithotripsy) this treatment involves high frequency ultrasound waves to break the stones into smaller fragments. This is inexpensive method that is not utilize commonly for gallstones. Rather, it is used more commonly in patients who have kidney stones. Patients with gallstones who have a solitary small stone (3 mm in diameter or less) are the best candidates. This therapy is usually combined with bile acid therapy. Patients have variable rates on clearance. These range between 50 to 90 percent.
	Contact dissolution: MBTE is a compound that allows for dissolution of gallstones. The gallstone must be washed with MBTE continuously for this to be effective. This is usually done through a tube placed in the gallbladder by a radiologist. At this time, 36 to 67 percent of patients can have partial dissolution of gallbladder stones.
	Oral bile acid therapy: chenodeoxycholic acid therapy will lower the cholesterol levels in bile acids. This decreases the saturation of cholesterol. Patients who then treated in this manner have 40 to 60 percent dissolution rates at the end of two years.

Contraindications: any of the above constitute contraindications to nonsurgical treatment of gallstones:

	Pigment stones.
	Stones with calcifications.
	Stones greater than 1.5 to 2.0 cm in diameter.
	Multiple stones.
	Abnormal either skin or oral or oral cholecystogram.
	Obesity
	Pregnancy.
	Liver disease.
	Lack of response after nine months worth of treatment.
	Poor patient compliance.

Side effects: with any of the above Seeker toward diarrhea may occur. Passage of small stones through the cystic duct and subsequently in the common bile duct do occur. Priceless in percent patients had abnormal liver function test. Elevated LDL levels also occur.

Stones may recur within 6 to 48 months depending upon the treatment selected by your physician. In many cases therapy must be continued indefinitely.

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