Gall bladder is one of the vital parts of the body, located below the liver.  It produces bile that helps in metabolising fats in the body. Gallstones, also known as cholelithiasis, are concretions formed due to abnormal constituents of bile. They can form in the gall bladder or anywhere in the biliary tree (ducts carrying bile).

Gallstones are the most common cause for damage to the gall bladder worldwide. They can occur at any age from 18 to 65 years but are more common in middle age and are three times more common in women. In fact, cholelithiasis is said to have a high association with 4 Fs — i.e. female, fat, forty, fertile.

Stones formed in the gall bladder are composed of cholesterol or pigment and also contain some amount of calcium salts.

The exact cause for formation of gallstones is not clear, but it is postulated to be linked to increased cholesterol production in the body. This is more in elderly women and obese people. If obese people lose weight rapidly, there is enhanced risk of gallstones. Impaired emptying of the gall bladder as it happens in pregnancy and or fasting states,   also leads to stasis of bile in the gall bladder and increased risk of cholesterol gallstones. Whenever there is increased break down of red blood cells inside the body, there is risk of predominant pigment stones, as in certain type of anaemias.  Infections of the biliary tree also lead to formation of pigment stones.  Cirrhosis of the liver makes one more prone to develop gallstones. Genetic susceptibility could also lead to gallstones.

Most times, gallstones cause no problem and may be detected accidentally. 10 per cent stones cause problems and need treatment. Symptoms occur if there are multiple gallstones or if there are a few big sized stones.  Presence of gallstones causes pain, commonly in the right upper half of the abdomen. Pain can be radiated to the right shoulder, even upper back. But it can even be felt in the central upper abdomen or even the right flank, thus mimicking other diseases.

Pain due to gallstones commonly appears after meals, more so after a fatty meal. It may be mild, tolerable or severe, excruciating and associated with nausea and vomiting. If infection and or inflammation (cholecystitis) sets in, high fever occurs with chills. Stones in the common bile duct can cause obstruction to flow of bile. Thus, along with pain, one develops jaundice, loss of appetite, vomiting, itching all over body and white coloured stool. Untreated cholecystitis can lead to perforation of the gall bladder which can be fatal.

Gallstones are suspected based on symptoms and physical examination.  Diagnosis is confirmed by X-rays and ultra sound of the abdomen.

Medical treatment consists of drugs which tend to dissolve the gallstones. Along with it, antibiotics are given for the infection, pain killers for pain, and fluid therapy is needed if there is dehydration due to vomiting and poor intake due to anorexia.

Drug therapy is useful if stones are less than 15 mm, problem is intermittent, mild to moderate and the person is lean.  But obese individuals or those having recurrent persistent or severe symptoms need surgical intervention.  Severe excruciating pain with vomiting and pain on touch is indicative of perforation of the gall bladder and is a surgical emergency.

A fat free diet, good physical exercise, avoiding alcohol and addicting substances are useful to prevent gall stones. Obese persons need to reduce weight but, slowly.  Those who already have symptomatic gall stones are advised to take a fat free diet and frequent small meals to take a load off the gall bladder.

Dr Rachna Pande, Specialist, internal medicine

rachna212002@yahoo.co.uk