What Are Gallstones?
More than 25 million people in the United States—up
to 15 percent of the population—have gallstones,
and one million people are diagnosed with gallstones
each year. Gallstones develop when bile stored
in the gallbladder hardens into stone-like chunks.
Their sizes range from a grain of sand to a
golf ball. Luckily, important advances have
been made in the last few years in the understanding
of gallstone disease and new remedies to treat
it.
What Are the Different Kinds of Gallstones?
There are two types of gallstones: cholesterol
stones and pigment stones.
| • |
Cholesterol
stones: Accounting for about 80 percent
of gallstones, cholesterol stones are
yellow-green and made primarily of hardened
cholesterol. |
| • |
Pigment
stones: Pigment stones are small dark
stones made of bilirubin. |
If gallstones get trapped in any of the ducts
that carry bile from the liver to the small
intestine—including the hepatic ducts,
which carry bile out of the liver, and the cystic
ducts, which take bile to and from the gallbladder—they
can block the normal flow of bile, causing the
gallbladder to become swollen. Gallstones can
also block the pancreatic duct, which carries
enzymes (chemicals that help the body digest
food) out of the pancreas, leading to an extremely
painful condition called gallstone pancreatitis.
If any of these ducts remain blocked for a significant
amount of time, the gallbladder, liver, or pancreas
could become infected. Warning signs of a serious
infection include fever, jaundice (yellowing
of the skin and whites of the eyes), and persistent
pain.
What Causes Gallstones?
Scientists don’t know what causes gallstones,
but research has shown some factors that tend
to increase people’s risk for developing
them.
| • |
High cholesterol
levels in the bile increase the risk for
cholesterol stones |
| • |
High amounts
of bilirubin in the bile increase the
risk for bilirubin (pigment) stones |
| • |
Incomplete
emptying of the gallbladder |
| • |
Foods high
in fat and cholesterol and low in fiber
may increase the risk for gallstones,
although scientists are not sure what
exact role diet has in the formation of
stones. |
What Are the Symptoms of a Gallstone Attack?
Gallstone attacks, which often follow fatty
meals, may occur during the night. Some people
with gallstones have no symptoms (called “silent
stones”). These silent stones do not interfere
with gallbladder, liver, or pancreas function,
and they do not require treatment.
The following symptoms may occur during a gallstone
attack:
| • |
Steady
pain in the upper abdomen that increases
rapidly and lasts from 30 minutes to several
hours |
| • |
Pain in
the back between the shoulder blades |
| • |
Pain in
the upper right shoulder |
| • |
Nausea
or vomiting |
| • |
Abdominal
bloating |
| • |
Recurring intolerance
of fatty foods |
| • |
Colic |
| • |
Belching |
| • |
Gas |
| • |
Indigestion. |
If you have symptoms of a gallbladder attack
and also experience sweating, chills, and fever,
you should see your doctor immediately.
Cholecystitis
Cholecystitis occurs when the gallbladder becomes
red and swollen. About 90 percent of cholecystitis
cases are caused by gallstones that block the
bile ducts. Because of this blockage, bile builds
up and pushes on the walls of the gallbladder,
causing inflammation. Other causes of cholecystitis
include infection, severe illness, alcohol abuse,
trauma, diabetes, or, rarely, a tumor.
What Are the Symptoms of Cholecystitis?
The primary symptom of cholecystitis is sudden
intense pain in the upper right side of the
abdomen, particularly after a fatty meal. Other
symptoms include:
| • |
Nausea
and vomiting |
| • |
Recurrent
painful attacks for several hours after
meals |
| • |
Pain that
extends to the lower part of the right
shoulder blade that may worsen with deep
breaths |
| • |
Shortness
of breath due to pain while inhaling |
| • |
Nausea |
| • |
Vomiting |
| • |
Stiff abdominal muscles,
especially on the right side |
| • |
Mild fever |
| • |
Chills |
| • |
Jaundice |
| • |
Abdominal bloating. |
Gallbladder Cancer
Gallbladder cancer is the fifth most common
cancer of the gastrointestinal tract; about
7,000 people are diagnosed with the disease
each year, and about 3,500 people die of gallbladder
cancer each year.
Gallbladder cancer is twice as common in women
as men, and white women are more likely than
black women to develop the disease. Most people
with gallbladder cancer are older than 70. Additionally,
people of certain nationalities in certain areas
are at a greater risk for gallbladder cancer.
For example, in New Mexico, gallbladder cancer
is diagnosed in five times as many Native Americans
than it is in whites.
What Are the Symptoms of Gallbladder Cancer?
Unfortunately, gallbladder cancer is difficult
to detect because the gallbladder is located
behind other organs; the disease is usually
not discovered until a person experiences symptoms
of gallbladder cancer or the gallbladder is
removed for other reasons.
Symptoms of gallbladder cancer are similar
to those of other gallbladder diseases, and
there may be no symptoms at all in the early
stages of the disease. If you experience any
of the following symptoms, visit your doctor
immediately.
| • |
Pain above
the stomach |
| • |
Weight
loss without trying |
| • |
Fever |
| • |
Yellowing
of the skin (jaundice). |
What Are the Different Stages of Gallbladder
Cancer?
Treating gallbladder cancer depends on how
far the disease has spread. There are three
stages of the disease:
| • |
Localized.
Cancer cells appear on the tissues on
the wall of the gallbladder, and they
can be completely removed with surgery.
|
| • |
Unresectable.
Cancer cells have spread to the liver,
stomach, pancreas, intestine, or lymph
nodes. Surgery cannot remove all of the
cancer. |
| • |
Recurrent.
The cancer cells have reappeared in
the gallbladder after treatment. |
Diagnosis | Treatments
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Diagnosing
Gallbladder Disease
If you are experiencing any of the symptoms
of gallbladder disease, talk to your doctor.
After a physical examination and a discussion
of your medical history, he or she might order
tests to rule out other diseases that have symptoms
similar to those of gallbladder disease, including
appendicitis, ulcers, irritable bowel syndrome,
pancreatitis, and jaundice.
Many gallstones, especially silent stones,
are found by accident during tests for other
problems. If your doctor thinks you might have
gallstones, he or she might order liver blood
tests to examine signs of infection, obstruction,
pancreatitis, or jaundice, which can occur if
too much bile is in the liver.
Radiographic Tests
Your physician could also order radiographic
tests, which use x-rays, to determine if you
have gallstones.
| • |
Ultrasound.
Ultrasound is the most sensitive and
most common test to help physicians diagnose
gallstones. During the test, sound waves
bounce off the gallbladder and other structures
inside your body to create an image. The
sound waves will also pick up any hard
objects, like gallstones. |
| • |
Oral
cholecystogram (OCG). During an OCG,
the physician takes x-rays of the person’s
gallbladder after the person swallows
pills that contain dye. |
Once gallstones have entered the bile duct,
they are harder to detect with these tests because
ultrasound is less sensitive in the bile duct
and OCG can’t be used at all. To help
identify any possible gallstones in the bile
duct, your physician might recommend an endoscopic
retrograde cholangiopancreatography, or ERCP.
During this procedure, a physician inserts dye
directly into the bile duct. Using a flexible
swallowed endoscopy tube attached to a computer
and TV monitor, he or she can locate and remove
stones.
Your physician may recommend one of the following
tests to detect gallstones:
| • |
Computed
tomographic (CT) scan, a detailed
cross-sectional x-ray image of the body,
may help detect gallstones or other complications.
|
| • |
Magnetic
resonance (MR) cholangiogram, the
injection of dye into the bile ducts in
order to examine the gallbladder and ducts
on an x-ray, may detect blocked bile ducts. |
| • |
Cholescintigraphy
(HIDA scan) is used to detect obstruction
or abnormal contractions of the gallbladder.
During this test, a person is injected
with a radioactive material that stimulates
the gallbladder to contract. |
| • |
Percutaneous
transhepatic cholangiography (PTC),
which involves using a needle with injection
of dye into the bile ducts and x-ray to
look for stones, also may detect gallstones. |
Diagnosing Cholecystitis
Like gallstones, the symptoms of acute cholecystitis
are similar to those of other illnesses, so
it is sometimes hard to diagnose. If your doctor
suspects that you might have cholecystitis,
he or she may perform one or more of the following
tests:
| • |
Abdominal
ultrasound |
| • |
Hepatobiliary
scintigraphy, an imaging technique that
allows the physician to examine the liver,
bile ducts, gallbladder, and upper part
of the small intestine |
| • |
Cholangiography |
| • |
CT scan. |
Diagnosing Gallbladder Cancer
If you think you might have gallbladder cancer,
talk to your doctor. After reviewing your symptoms
and any possible risk factor you might have,
he or she may give you a physical exam. During
the physical, your doctor might check your abdomen
for extra fluids, examine your skin and eyes
for signs of jaundice, and look for swollen
lymph nodes to help determine if the cancer
has spread there.
Your physician could also recommend other diagnostic
tests.
Blood Tests
Your doctor may order a blood test to measure
the level of bilirubin in your blood. A high
bilirubin level indicates possible gallbladder
or liver problems. Your doctor could also order
tests to detect levels of the chemicals alkaline
phosphatase and aspartate aminotransferase and
the tumor markers CEA and CA 19-9, which can
indicate gallbladder cancer.
Diagnostic Tests
Your doctor could also recommend one of the
following tests to help detect gallbladder cancer.
| • |
Ultrasound.
Ultrasound can identify about one
half of gallbladder cancers, and the pattern
of sound wave echoes can help distinguish
some types of benign tumors from malignant
ones, as well as whether the cancer has
invaded the liver. |
| • |
CT scan.
A CT scan can often determine the
location of the cancer cells, and they
are also used to determine how far the
cancer has spread. CT scans also can be
used to help guide a biopsy needle into
a suspected tumor (or CT-guided needle
biopsy). |
| • |
MR imaging
(MRI). MRI scans use radio waves and
strong magnets instead of x-rays to produce
detailed images of the body. The energy
from the radio waves is absorbed and released
in certain patterns depending upon the
type of tissue (or diseased tissue) they
enter. Although most doctors prefer CT
scans as a first step at looking at the
gallbladder, the MRI produces more detailed
information. |
| • |
Angiography.
Angiography is an x-ray procedure
used to examine blood vessels. A small
amount of dye is injected into an artery
to highlight blood vessels, and then x-ray
images are taken to allow the doctor to
see if blood flow to the area is blocked
by a tumor or if there are any abnormal
blood vessels in the gallbladder area.
It can also reveal if a tumor has grown
through the walls of blood vessels or
the wall of the gallbladder. |
| • |
Cholangiography.
|
| • |
ERCP. |
| • |
Laparoscopy. During
this procedure, a doctor inserts a thin
lighted tube through an incision in the
front of the abdomen to examine the gallbladder,
liver, and area around the gallbladder
to detect how much the cancer has spread.
|
| • |
Biopsy. During
this procedure, a thin needle is inserted
into the gallbladder to draw a sample
of the tumor. The sample is then examined
under a microscope to determine whether
it is cancerous.
|
Diagnosis | Treatments
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Treating
Gallbladder Disease
Treating Gallstones
Researchers have developed new methods of treating
gallbladder cancer during the last few years,
but surgical removal of the gallbladder (a procedure
known as cholecystectomy) remains the most popular
therapy. Although newer nonsurgical treatments
are useful in only some people, surgery can
be used in nearly all people with gallstones.
Surgery
Each year, more than 500,000 Americans have
gallbladder surgery.
| • |
Open
cholecystectomy. During this procedure,
the surgeon removes the gallbladder through
a five- to eight-inch incision. People
who undergo this procedure usually remain
in the hospital for four or five days
and then recover at home for a few weeks.
|
| • |
Laparoscopic
cholecystectomy: Introduced in the
United States in 1998, this technique
is now used in 90 percent of all cholecystectomies.
During this procedure, the surgeon makes
several incisions in the belly button
and inserts a tiny video camera that transmits
a picture to the TV screen in the operating
room, which guides the surgeon as he removes
the gallbladder. Because abdominal muscles
are not cut in this procedure, there is
less pain, quicker recovery time, and
fewer scars with this technique. |
Nonsurgical Treatments
Your physician might not recommend surgery
if you have cholesterol stones or if you have
another medical condition that would make surgery
difficult. Unfortunately, gallstones can appear
after nonsurgical treatments.
| • |
Oral
medications. Drugs made from bile
acid—including ursodiol (Actigall)
and chenodiol (Chenix)—dissolve
the stones. These drugs work best on small
cholesterol stones, and months or years
of treatment may be necessary before all
the stones are dissolved. |
| • |
Contact
dissolution therapy. When it’s
injected directly into the gallbladder,
a drug called methyl tertbutyl ether seems
to dissolve stones. Some stones dissolve
in as little as 1 to 3 days. |
| • |
Extracorporeal
shockwave lithotripsy (ESWL): This
treatment uses shock waves to break up
stones into smaller pieces that can pass
more easily through bile ducts and avoid
blockages. However, intense pain can follow
treatment, and the long-term success rate
is not known.
|
Treating Cholecystitis
Initial treatment for cholecystitis usually
involves hospitalization, where the person is
fed intravenously. Although cholecystitis may
resolve itself without treatment, cholecystectomy
(surgery to remove the gallbladder) may be necessary
if inflammation is persistent. The surgery is
performed as soon as possible after a person
is diagnosed with cholecystitis.
Nonsurgical treatments of cholecystitis include
medications to control pain, antibiotics to
help wipe out the infection, and a low-fat diet.
Treating Gallbladder Cancer:
There are different options to treat gallbladder
cancer. Ask your doctor which method is best
for you.
Surgery
When gallbladder cancer has not spread to surrounding
tissues, surgery is a common treatment. Your
doctor may remove your gallbladder and, possibly,
some of the surrounding lymph nodes. If the
cancer has spread and cannot be removed or if
it’s blocking the bile ducts, your doctor
may perform surgery to relieve symptoms or perform
a biliary bypass, which involves cutting the
gallbladder or bile duct and sewing it to the
small intestine. Your doctor may also insert
a catheter into the gallbladder to drain excess
bile.
Radiation
Radiation may be used alone or with surgery.
Radiation for gallbladder cancer usually comes
from an external machine (external-beam radiation
therapy).
Chemotherapy
Chemotherapy, during which anticancer drugs
are injected into the bloodstream, may be given
along with radiation to make cancer cells more
sensitive to the radiation (radiosensitizers).
Diagnosis | Treatments
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Current Research
Gallstone Research
Scientists are researching whether a combination
of different therapies, including lithotripsy
and medications, may be more effective in dissolving
gallstones that just one treatment option.
Cholecystitis Research
Scientists are trying to determine whether
how quickly a person is diagnosed affects their
treatment options. For example, a study published
in American Family Physician about the effect
of a delayed diagnosis on a person’s outcome
found that people who didn’t see their
doctor when they first had symptoms of cholecystitis
were much more likely to require open surgery
than those who sought medical help right away.
Gallbladder Cancer Research
Research on the causes, diagnosis, and treatment
of gallbladder cancer is currently underway
all over the world, including the following
therapies:
| • |
Chemotherapy
and radiation therapy: Scientists
are looking into new ways of making radiation
more effective. They’re also looking
at new chemotherapy drugs and the use
of old chemotherapy medications in combination
with other treatments. |
| • |
Immunotherapy:
Experimental treatments that boost a patient’s
immune response are being tested as a
method to fight gallbladder cancer, including
the use of interleukin-12 (IL-12). |
| • |
Gene
therapy: A protein from an altered
form of the cold virus, ONYX-15, which
can kill cancer cells, is being tested
as a possible therapy for gallbladder
cancer. |
Diagnosis | Treatments
| Research | Future | References | Return
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Towards
the Future
Research on all gallbladder treatments continues
to move forward, so new treatments are likely
to be available in the future.
| • |
Chemotherapy
medications. Researchers will study
the effectiveness and safety of rebeccamycin
analogue, a chemotherapy drug, in treating
people who have advanced liver and/or
gallbladder cancer. |
| • |
Lithotripsy.
Scientists are also studying how successfully
lithotripsy treats single noncalcified
gallstones that are 4 to 20 mm in diameter.
|
Diagnosis | Treatments
| Research | Future | References | Return
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References
1. “Gallbladder
Disease,” MEDLINEplus Medical Encyclopedia,
National Library of Medicine (NLM), May 1, 2002.
2. “Gallstones,”
The American Gastroenterological Association,
2002.
3.
“About Cholecystectomy: Surgical Removal
of the Gallbladder,” American College
of Surgeons, 2003.
4. “Gallstones,”
National Institute of Diabetes and Digestive
and Kidney Diseases (NIDDK), March 2002.
5. “Acute
Cholecystitis,” Journal of the American
Medical Association, Jan. 1, 2003.
6. “Acute
Cholecystitis (Gallstones),” MEDLINEplus
Medical Encyclopedia, NLM, Nov. 18, 2002.
7. “What
Are the Key Statistics for Gallbladder Cancer?”
American Cancer Society (ACS), 2003.
8. “Gallbladder
Cancer,” National Cancer Institute
(NCI), Aug. 22, 2002.
9. “Treatment
of Gallstone and Gallbladder Disease,”
National Guideline Clearinghouse, May 2000.
10. “Cholelithiasis,”
MEDLINEplus Medical Encyclopedia, Jan. 29, 2002.
11. “How
Is Gallbladder Cancer Diagnosed?”
ACS, 2003.
12. “Lithotripsy
for the Treatment of Gallstones,”
ClinicalTrials.gov, November 2002.
13. “Lithotripsy,”
MEDLINEplus Medical Encyclopedia, NLM, Nov.
12, 2001.
14. “Cholecystitis
Is Complicated by Delayed Diagnosis,”
American Family Physician, March 1, 2000.
15. “What’s
New in Gallbladder Cancer Research and Treatment?”
ACS, 2003.
16. “Rebeccamycin
Analogue in Treating Patients with Advanced
Liver and/or Biliary Cancer,” ClinicalTrials.gov,
February 2002.
Diagnosis | Treatments
| Research | Future | References | Return to
Top
Writer: Elizabeth Shimer
Clinical Reviewer: Patt Panzer, MD, MPH
Editors: Andrea King, Joanne Poeggel
Source of Material: Rockhill Communications,
14 Rock Hill Road Bala, Cynwyd, PA 19004, (610)
667-2040, http://www.rockhillcommunications.com
Date Written: 5/18/03
Date Last Revised: 5/30/03
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