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Gallstones and Gallbladder Disease

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of gallstones.

Alternative Names

Cholecystitis; Choledocholithiasis; Common Bile Duct Stones; Lithotripsy

Prognosis

Asymptomatic gallstones seldom lead to problems. Death from even symptomatic gallstones is very rare, accounting for only 0.2% of annual deaths in the United States. Serious complications are rare and, if they occur, usually develop from stones in the bile duct or after surgery.

Gallstones, however, can cause obstruction at any point along the ducts that carry bile and, in such cases, symptoms can develop:

  • In most cases of obstruction, the stones block the cystic duct, which leads from the gallbladder to the common bile duct. This can cause pain (biliary colic), infection and inflammation (acutecholecystitis), or both.
  • About 10% of patients with symptomatic gallstones also have stones that pass into and obstruct the common bile duct (called choledocholithiasis).

Complications of Acute Cholecystitis (Gallbladder Inflammation)

The most serious complication of acute cholecystitis is infection, which develops in about 20% of cases. It is extremely dangerous and life-threatening if it spreads to other parts of the body (septicemia). Symptoms include fever, rapid heartbeat, fast breathing, and mental confusion. Among the conditions that can lead to septicemia are the following:

  • Gangrene or Abscesses. If acute cholecystitis is untreated and becomes very severe, inflammation can cause abscesses or destroy enough tissue in the gallbladder (called necrosis) to lead to gangrene. Studies have reported this complication in between 2% to 30% of cases. The highest risk is in men over 50 with a history of heart disease who have high levels of infection.
  • Perforated Gallbladder. An estimated 10% of people with acute cholecystitis have a perforated gallbladder, which is a life-threatening condition. In general, this occurs in people who wait too long to seek help or who do not respond to treatment. This condition is most common in people with diabetes. The risk for perforation increases with a condition called emphysematous cholecystitis, in which gas forms in the gallbladder. Once the gallbladder has been perforated, people may experience a temporary decrease in pain. This is a dangerous event, however, since peritonitis (wide spread abdominal infection) develops afterward.
  • Empyema. Pus in the gallbladder (called empyema) occurs in 2% to 3% of patients with acute cholecystitis. Abdominal pain is usually severe and is typically present for more than seven days. The physical exam is not distinctive. The condition can be life threatening, particularly if the infection spreads to other parts of the body.
  • Fistula. In some cases, the inflamed gallbladder adheres to and perforates nearby organs, such as the small intestine. In such cases a fistula (a channel) between the organs develops. Sometimes, in these cases, gallstones can actually pass into the small intestine, which can be very serious without immediate surgery.

Prompt surgery can nearly always prevent these complications.

Complications from Choledocholithiasis (Stones in the Common Bile Duct)

When gallstones lodge in the common bile duct (choledocholithiasis) instead of the gallbladder, serious complications can occur.

Infection in the Common Bile Duct (Cholangitis). Infection in the common bile duct (cholangitis) from obstruction is common and serious. Those at highest risk for a poor outlook also have one or more of the following conditions:

  • Kidney failure.
  • Liver abscess.
  • Cirrhosis.
  • Being over 50 years.

If antibiotics are administered immediately, the infection clears up in 75% of patients. If cholangitis does not improve, the infection may spread and become life threatening. Either surgery or a procedure known as endoscopic sphincterotomy is required to open and drain the ducts.

Pancreatitis. Choledocholithiasis is responsible for most cases of pancreatitis (inflammation of the pancreas), a condition that can be life threatening. The pancreatic duct, which carries digestive enzymes, joins the common bile duct right before it enters the intestine. It is therefore not unusual for stones that pass through or lodge in the lower portion of the common bile duct to obstruct the pancreatic duct.

Pancreas

Gallbladder Cancer

Gallstones are present in about 80% of people with gallbladder cancer. Symptoms of gallbladder cancer are usually not present until the disease has reached an advanced stage and may include weight loss, anemia, recurrent vomiting, and a lump in the abdomen. When the cancer is caught at an early stage and has not spread deeper than the mucosa (the inner lining), removal of the gallbladder results in five-year survival rates of 68%. If cancer has spread to deeper layers, more extensive surgery or other treatments may be required.

This cancer is very rare, however, even among people with gallstones. Certain conditions in the gallbladder, however, pose a higher than average risk for cancer.

Gallbladder Polyps and Primary Scerlosing Cholangitis. Polyps (growths) are sometimes detected during diagnostic tests for gallbladder disease. Small gallbladder polyps (up to 10 mm) pose little or no risk, but large ones (greater than 15 mm) pose some risk for cancer, so the gallbladder should be removed. Patients with polyps 10 to 15 mm have a lower risk but they should still discuss removal of their gallbladder with their physician.

Primary Sclerosing Cholangitis. Primary sclerosing cholangitis is a rare disease that causes inflammation and scarring in the bile duct. It is associated with a lifetime risk of 7% to 12% for gallbladder cancer. The cause is unknown although it tends to strike younger men with ulcerative colitis. Polyps are often detected in this condition and have a very high likelihood of malignancy.

Anomalous Junction of the Pancreatic and Biliary Ducts. With this rare inborn condition, the junction of the common bile duct and main pancreatic duct is outside the wall of the small intestine and forms a long channel between them. This problem poses a very high risk for cancers in the biliary tract.

Porcelain Gallbladders. Gallbladders are referred to as porcelain when their walls have become so calcified that they look like porcelain on an x-ray. Porcelain gallbladders have been associated with a very high risk for cancer, although recent evidence suggests that the risk is lower than previously thought. The incidence appears to depend on the presence of specific factors, such as partial calcification involving the mucosal lining. This condition may develop from a chronic inflammatory reaction that may actually be responsible for the cancer risk. Studies are reporting no higher risk with "true" porcelain gallbladders, in which the gallbladder walls are entirely calcified.

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