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Gall Stones

What are gall stones?

Also known as cholelithiasis, gallstones are formations of the biliary tract that are present in the gall bladder. They remain asymptomatic for a very long time and develop insidiously. The associated risk is the migration of a gall stone into the cystic duct opening. During the contraction of the gall bladder, it may obstruct the bile outflow. A biliary colic develops due to tension of the gall bladder wall. When pain persists due to cystic duct obstruction, it results in acute cholecystitis. When one or more gall stones are present in the common bile duct, it is called choledocholithiasis. This is a consequence of migration of the gall stones from the gall bladder into the bile duct.

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Causes

The concentrations of substances present in the bile approach their limits of solubility. This presence of bile in the gall bladder gets supersaturated precipitating into microscopic crystals that get trapped in the mucus of the gall bladder producing sludge. As these crystals grow, they form into macroscopic stones. Complications arise when the sludge occludes the duct.

Symptoms

Gall stone formations can be divided into 4 stages:

  1. Lithogenic state – conditions ideal for the formation of the gall stone

  2. Asymptomatic gall stones – they are present in the gall bladder without causing any evident symptoms. They are discovered incidentally and coexist with gastrointestinal disorders.

  3. Symptomatic gall stones (onset of biliary colic) – during gall bladder contraction, the sludge propitiously impacts the cystic duct, increasing gall bladder wall tension.

  4. Complex cholelithiasis

Other symptoms

  • Dyspepsia

  • Indigestion

  • Belching

  • Intolerance to fat

  • Bloating

  • Postprandial epigastric pain radiating to the back and the right shoulder

  • Nausea and vomiting

  • Upper right quadrant tenderness

  • Fever

  • Murphy’s sign or jaundice – yellow discoloration of the skin

Diagnosis

Physical examination reveals tenderness in the upper right quadrant and a palpable infiltrate is exhibited.

Blood studies conducted should include a CBC differential count, amylase, lipase, liver function panel and blood culture.

Abdominal radiography is taken by placing the patient in an upright and supine position. Mixed gall stones containing sufficient calcium will appear opaque on plain films.

Ultrasonography captures gall stones as echogenic foci within the gall bladder. The study is especially useful in the diagnosis of acute cholecystitis.

CT scan or computed tomography is used to take images of the abdominal viscera in the presence of abdominal pain.

MRI or magnetic resonance imaging is done along with cholangiopancreatography (MRCP) for non-invasive investigation of gall stones in the bile duct and the biliary tract.

Medical management

Dissolution of gall stones can be attempted with ursodiol or ursodeoxycholic acid. This suppresses the secretion of cholesterol and impedes the intestinal absorption of the cholesterol. Actigall, Urso 250, Urso Forte are all used to treat non-calcified gall bladder stones < 20 mm in diameter.

Dr. Deepak is a surgical practitioner having treated several cases of cholelithiasis with medical as well as surgical management.

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