Dr. Akshay Akulwar

Gallstones Treatment

Gallbladder stones, or gallstones, are solid particles that develop in the gallbladder, a small organ located under the liver. The gallbladder’s main function is to store and release bile, a fluid made by the liver that aids in digesting fats.

Gallstones can vary in size, from tiny sand-like particles to larger stones resembling pebbles. They can be composed of cholesterol, bilirubin (a waste product from the breakdown of red blood cells), or a combination of both.

Gallstones may not cause symptoms in some people and can remain asymptomatic for long. However, they can cause various health issues if they obstruct the bile ducts, which are tubes that carry bile from the gallbladder to the small intestine. When a gallstone blocks the bile ducts, it can cause severe abdominal pain, known as a gallbladder attack.

What are the various types of stones found in the gallbladder?

Gallstones can be classified into two main types based on their composition:

Cholesterol Stones: Cholesterol stones are the most common type of gallbladder stones. It accounts for approximately 80 to 85% of cases. These stones primarily comprise cholesterol, a fatty substance found in the bile. These stones can vary in size and color, ranging from yellow to green. Cholesterol stones develop when there is an imbalance in the components of bile, resulting in excess cholesterol and a reduction in bile salts and lecithin (a type of fat).

Pigment Stones:
Pigment stones are primarily formed of bilirubin, a pigment that is a waste product from the breakdown of red blood cells. It is also made up of calcium salts that are found in bile. These stones are generally smaller and darker in color, unlike cholesterol stones. Pigment stones can form when there is excessive bilirubin in the bile or when the bile contains fewer bile salts to keep the bilirubin in a soluble form.

What methods are used to diagnose gallbladder stones?

Doctors diagnose gallbladder stones by reviewing a patient’s medical history, conducting a physical exam, and ordering lab and imaging tests. They will inquire about your symptoms and assess whether you have any health conditions or risk factors that increase the likelihood of developing gallstones.

The healthcare provider might inquire about your family history of gallstones and your usual diet. During the physical exam, the doctor will assess your body and look for abdominal pain or other indicators of gallbladder problems. Below are the common tests used to diagnose gallbladder stones:

Abdominal Ultrasound: This is the most frequently used imaging test to detect gallstones. It involves sliding a device called a transducer across the stomach area. The transducer sends signals to a computer, which generates images of the structures within your abdomen.

Endoscopic Ultrasound (EUS): This procedure is useful for detecting smaller gallbladder stones that might not be visible with an abdominal ultrasound. During EUS, a thin tube (endoscope) is passed through the mouth and down the digestive tract. A tiny ultrasound device on the end of the tube emits sound waves, creating detailed images of the surrounding tissue.

CT Scan (Computed Tomography): A CT scan is used to obtain clearer, more detailed images of the gallbladder and nearby organs. It is especially helpful when there are concerns about complications from gallstones or if the results from an ultrasound are inconclusive.

Endoscopic Retrograde Cholangiopancreatography (ERCP): ERCP is a procedure used to diagnose and treat issues in the bile and pancreatic ducts. During the procedure, an endoscope is passed through the mouth, esophagus, stomach, and into the duodenum to view the ducts. A dye is injected into the ducts, allowing X-ray images to reveal any gallstones that may have entered the bile ducts.

MRCP Magnetic resonance cholangiopancreatography (MRCP) is a specialized type of MRI that provides detailed images of the bile ducts. This non-invasive procedure offers clear visualization of the biliary system, including the common bile duct.

Cholescintigraphy (HIDA Scan): This nuclear medicine test evaluates the functioning of the gallbladder and biliary system. A radioactive tracer is injected into the bloodstream, and a special camera tracks its absorption and excretion by the liver and gallbladder.

Cholescintigraphy: This test uses a radioactive substance to capture images of the biliary tract. The radioactive material is injected into a vein in the arm, and a special camera tracks its movement through the biliary system. This helps diagnose issues like abnormal gallbladder contractions or bile duct blockages.

Blood tests: These tests can detect infections, jaundice, pancreatitis, or other complications related to gallbladder stones.

What are the different treatment options for gallbladder stones?

Gallbladder stones can be treated with both surgical and non-surgical methods. The choice of treatment depends on factors such as the size and number of stones, the presence of symptoms, the risk of complications, and the patient's overall health. Here’s a look at the available treatment options for gallbladder stones:

Non-surgical treatment for Gallstones :

Non-surgical treatments for gallstones focus mainly on relieving symptoms and, in some cases, trying to dissolve small stones. These treatments include the following:

Observation and Monitoring: If gallstones are asymptomatic and not causing any issues, they may be monitored without immediate treatment. Your doctor might recommend regular follow-ups and imaging tests to detect any changes or the onset of symptoms.

Medications: To help dissolve gallstones gradually, doctors may prescribe medications, with Ursodeoxycholic acid (UDCA) being the most commonly used. UDCA reduces cholesterol production in the liver, aiding in the breakdown of cholesterol gallstones. Other effective chemicals, such as ursodiol or chenodiol, are also available in oral bile acid pills. These medications work by thinning the bile, which helps dissolve the gallstones.

Extracorporeal Shock Wave Lithotripsy (ESWL): This non-invasive procedure employs shock waves to fragment gallbladder stones into smaller pieces, allowing them to pass more easily out of the gallbladder. ESWL is mainly used for patients with small cholesterol stones who are not eligible for surgery.

MTBE Injection: This non-surgical treatment involves injecting a solvent called methyl tertiary-butyl ether (MTBE) into the gallbladder to dissolve gallstones. MTBE works quickly to dissolve the stones, although it may cause side effects, including burning pain.

Endoscopic Drainage: This non-surgical method is used to manage complications from gallstones that block the bile ducts. It involves using an endoscope inserted through the mouth to access the cystic duct. A wire is then placed into the gallbladder and coiled to mimic the natural flow of bile from the gallbladder to the small intestine.

Surgical treatment for Gallstones :

Surgical treatment for gallstones typically involves removing the gallbladder, a procedure called cholecystectomy. This surgery is often necessary when gallstones cause symptoms or complications, providing long-term relief. About 80 percent of those with symptomatic gallstones will need this surgery.

There are two primary types of cholecystectomy:

Laparoscopic Cholecystectomy (keyhole surgery): It is the most common and effective treatment for gallbladder stones. This procedure involves making several small incisions in the abdomen. Through these incisions, a laparoscope (a thin, flexible tube with a camera) and surgical instruments are inserted. The abdomen is inflated with carbon dioxide to create space for the surgeon. The laparoscope displays images of the gallbladder and surrounding structures on a monitor, allowing the surgeon to detach the gallbladder from its connections, including the bile duct and blood vessels.

Once the gallbladder is separated, it is pulled out through one of the small incisions. The remaining incisions are closed, and the surgery is complete. Laparoscopic cholecystectomy is minimally invasive, resulting in minor pain, faster recovery, and smaller scars than open surgery.

Open Cholecystectomy: When laparoscopic cholecystectomy is not suitable, an open cholecystectomy may be performed. This procedure involves making a larger incision in the abdomen to directly access and remove the gallbladder. Open cholecystectomy is typically used in cases with complications, extensive scarring from previous surgeries, or specific medical conditions that make laparoscopic surgery difficult.

Gallstone Size Criteria for Surgery

When determining the need for surgery, the size of gallstones is an important factor in assessing their potential danger. Gallstones are usually measured in millimeters (mm) and can range from 2 mm to several centimeters. Small gallstones, less than 2 mm, often cause no symptoms and are generally monitored without treatment. However, if gallstones exceed 2 mm in size, the risk of complications increases.

Gallstones ranging from 3 to 5 mm in size can lead to mild to moderate symptoms, including abdominal pain and indigestion. While these symptoms can often be managed with medication and dietary adjustments, surgery may be necessary if the symptoms worsen.

Gallstones measuring between 5 mm and 10 mm are classified as intermediate in size and can lead to moderate to severe symptoms. Medication and dietary changes are typically less effective for this size, making surgery a common recommendation from healthcare professionals. Additionally, there is a higher risk of complications, such as cholecystitis, with these larger gallstones.

Gallstones larger than 10 mm carry a significant risk of complications, making surgery the most common recommendation. These larger stones can obstruct the gallbladder or digestive tract, potentially leading to issues such as pancreatitis. It is crucial to seek medical attention promptly if gallstones exceed 10 mm to assess the risk of these serious complications.

What are the advantages of laparoscopic surgery for gallbladder stones?

Laparoscopic surgery for gallstones offers several advantages over traditional open surgery. Your healthcare provider will determine whether laparoscopic or open cholecystectomy is more suitable for you. Here are some of the benefits of laparoscopic surgery for gallbladder stones:

Minimally Invasive: Laparoscopic cholecystectomy is a minimally invasive procedure that results in smaller scars and less damage to surrounding tissues compared to the larger incision required for open surgery.

Reduced Pain: The smaller incisions and minimized tissue damage associated with laparoscopic surgery result in less postoperative pain and discomfort compared to open surgery. This often leads to a quicker recovery and shorter hospital stays.

Laparoscopic cholecystectomy typically enables faster recovery, with many patients able to resume daily activities and return to work within a few days to a week after the procedure.

Reduced Risk of Complications: Laparoscopic surgery is associated with a lower risk of complications, including wound infections and incisional hernias.

Cosmetic Benefits: The smaller incisions used in laparoscopic cholecystectomy lead to smaller, less noticeable scars, which can be more aesthetically pleasing for patients.

Efficient Stone Removal: Laparoscopic cholecystectomy is very effective at removing gallstones, offering long-term relief from symptoms associated with gallstones.

Enhanced Visualization: Laparoscopic procedures offer surgeons high-definition views of the surgical area through a laparoscope, improving precision and effectiveness in performing the surgery.

Minimized Bowel Disturbance: Laparoscopic cholecystectomy maintains the bile duct and surrounding structures, resulting in a lower risk of postoperative bowel issues, such as diarrhea or fat malabsorption.