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Introduction of gallbladder
The gallbladder is a small, pouch-like organ situated underneath the liver. The
main purpose of the gallbladder is to store and concentrate bile.
Anatomically, the gallbladder is divided into three sections: the fundus, body,
and neck.
According to histological, The layers of the gallbladder wall are:
The epithelium is the innermost layer of the gallbladder, and is of simple
columnar type. Underneath the epithelium is a lamina propria; together,
these two layers are known as the mucosa.
The submucosa is a thin layer of loose connective tissue with smaller blood
vessels. It contains many elastin fibres, lymphatics, and in the neck of the
gallbladder, glands which secrete mucus. The lymphatics of this layer help
to drain water when the bile is concentrated, and the mucous glands may
create a surface that protects the wall of the biliary tree.
The muscular layer, formed by smooth muscular tissue.
The perimuscular ("around the muscle") fibrous tissue, another layer of
connective tissue
The serosa is a thick layer that covers the outer surface of the gallbladder,
and is continuous with the peritoneum, which lines the abdominal cavity.
The serosa contains blood vessels and lymphatics.
Bile is a liquid produced by the liver, which helps digest fats. It is passed from
the liver through a series of channels, known as bile ducts, into the gallbladder.
The bile is stored in the gallbladder and over time it becomes more concentrated,
which makes it better at digesting fats. The gallbladder is able to release bile into
the digestive system when it is needed.

II.Definition of gallstones
A gallstone is a solid crystal deposit in the gallbladder that form from calcium
salts and bile pigments. Gallstones are formed in the gallbladder but may pass
distally into other parts of the biliary tract such as the cystic duct, common bile
duct, pancreatic duct or theampulla of Vater. Rarely, in cases of severe
inflammation, gallstones may erode through the gallbladder into adherent bowel
potentially causing an obstruction termed gallstone ileus. Cholesterol is a normal
component of bile, and usually remains dissolved. However, when the bile
becomes oversaturated with cholesterol, small crystals form. These crystals are
trapped in mucus within the gallbladder, and gradually grow. Gallstones can

migrate to other parts of the digestve tract and cause severe pain with life
-threatening complication. Gallstones can be as small as grains of sand or as large
as golf balls..

III. Causes
What causes gallstones is not clear. Most gallstones are made up of cholesterol,
a type of fat made in the liver and obtained from some foods.
Gallstones may form when:
the liver releases too much cholesterol into the bile
there are not enough bile salts in the bile to dissolve the cholesterol
there are other substances in the bile that cause the cholesterol to form
the gallbladder does not empty completely or often enough, which
concentrates the bile

Gallstones are more common among women and adults ages 40 and older than
among other groups. The female sex hormone estrogen may help explain why
gallstones are more common among women than among men. Estrogen may
increase the amount of cholesterol in the bile and decrease gallbladder movement,
which may lead to gallstones.
Other factors that may increase your chances of developing gallstones are these:
family history of gallstones
high triglycerides (a type of fat in the blood)
lack of physical activity
low HDL (good) cholesterol
obesity, particularly a large waist size
rapid weight loss
Some drugs may also increase your chances of getting gallstones. Among them
are drugs that have estrogen, such as birth control pills and hormone replacement
therapy (medicine that may be given to some women to address problems related
to menopause). Taking drugs that lower cholesterol levels in the blood may also
make it more likely that you will develop gallstones, as some of these drugs may
make the liver release more cholesterol into the bile.

IV. Epidemiology of gallstones

Diseases of the gallbladder are common . The best epidemiological screening
method to accurately determine point prevalence of gallstone disease is
ultrasonography. Many risk factors for cholesterol gallstone formation are not
modifiable such as ethnic background, increasing age, female gender and family
history or genetics. Conversely, the modifiable risks for cholesterol gallstones are
obesity, rapid weight loss and a sedentary lifestyle.. Gallstone disease in childhood,
once considered rare, has become increasingly recognized with similar risk factors
as those in adults, particularly obesity. Gallbladder cancer is uncommon in
developed countries. In the U.S., it accounts for only ~ 5,000 cases per year.
Elsewhere, high incidence rates occur in North and South American Indians. Other
than ethnicity and female gender, additional risk factors for gallbladder cancer
include cholelithiasis, advancing age, chronic inflammatory conditions affecting

the gallbladder, congenital biliary abnormalities, and diagnostic confusion over

gallbladder polyps.
More than 25 million Americans have gallstones, and a million are diagnosed each
year. However, only 1 - 3% of the population complains of symptoms during the
course of a year, and fewer than half of these people have symptoms that return.

V. Classification

Types of gallstones that can form in the gallbladder include:

1.Cholesterol gallstones.

The most common type of gallstone, called a cholesterol gallstone, often

appears yellow in color. These gallstones are composed mainly of undissolved
cholesterol, but may contain other components.

2.Black Pigment stones

Pigment stones are small and dark and comprise bilirubin (Insoluble bilirubin
pigment polymer) and calcium (calcium phosphate) salts that are found in bile,
usually black and multiple. They contain less than 20% of cholesterol (or 30%,
according to the Japanese-classification system).

3.Mixed stones (Brown pigment stone)

Mixed gallstones typically contain 2080% cholesterol (or 3070%, according to
the Japanese- classification system).[26] Other common constituents are calcium

carbonate, palmitate phosphate, bilirubin and other bile pigments (calcium

bilirubinate, calcium palmitate and calcium stearate). Because of their calcium
content, they are often radiographically visible

4. Stones with Calcium Content

5 to 20% of the solid content of the gallstone are calcium carbonate. Presence of
calcium carbonate makes stone radio-opaque.

VI. Sympstoms

The gallbladder isn't an organ that gets a lot of attention unless it's causing
you pain. A person usually learns he or she has gallstones while being examined
for another illness. Typically the gallbladder doesn't cause too many problems or
much concern, but if something slows or blocks the flow of bile from the
gallbladder, a number of problems can result. Gallstones may cause pain known as
biliary colic, but about 90 percent of people with gallstones w ill have no
symptoms. Most symptomatic gallstones have been present for a number of years.
For unknown reasons, if you have gallstones for more than 10 years, they are less
likely to cause symptoms.
Inflammation of the gallbladder (cholecystitis ) can be caused by gallstones,
excessive alcohol use, infections, or even tumors that cause bile buildup. But the
most common cause of cholecystitis is gallstones. The body can react to the
gallstone irritation by causing the gallbladder walls to become swollen and painful.
The episodes of inflammation can last for several hours, or even a few days. Fever
is not unusual.
Specific symptoms may vary based on what type of gallbladder condition you
have, although many symptoms are common among the different types of
gallbladder problems.
But most gallbladder symptoms start with pain in the upper abdominal area,
either in the upper right or middle.

Below are common symptoms of gallbladder conditions:

Severe abdominal pain
Pain that may extend beneath the right shoulder blade or to the back

Pain that worsens after eating a meal, particularly fatty or greasy foods
Pain that feels dull, sharp, or crampy
Pain that increases when you breathe in deeply
Chest pain
Heartburn, indigestion, and excessive gas
A feeling of fullness in the abdomen
Vomiting, nausea, fever
Shaking with chills
Tenderness in the abdomen, particularly the right upper quadrant
Jaundice (yellowing of the skin and eyes)
Stools of an unusual color (often lighter, like clay)
Some gallbladder problems, like simple gallstones that are not blocking the
cystic duct, often cause no symptoms at all.
They're most often discovered during an X-ray or CT scan that's performed to
diagnose a different condition, or even during an abdominal surgery.
If you spot any symptoms of gallbladder trouble, head to your doctor for a
diagnosis and prompt treatment to get your digestive tract running smoothly again.

Your doctor will perform a physical examination that includes checking your
eyes and skin for visible changes in color. A yellowish tint in your skin or eyes may
be signs of jaundice. Too much bilirubin in your body causes jaundice.The
examination may involve using diagnostic testing to see inside your body.
These tests include:
Ultrasound tests produce images of your abdomen. This is the preferred
imaging method to initially confirm that you have gallstone disease.

2.Abdominal CT Scan
This is an imaging test that takes pictures of your liver and abdominal region.
3.Gallbladder Radionuclide Scan
This is a very important scan that takes about one hour to complete. A
specialist injects a radioactive substance into your veins. The substance travels
through your blood to the liver and gallbladder. It highlights any infection or
blockages in these organs.
4.Blood Tests
Your doctor may order blood tests that measure the amount of bilirubin in
your blood. The tests also help determine how well your liver is functioning.


Cholesterol gallstones can sometimes be dissolved by oral ursodeoxycholic acid,
but it may be necessary for the patient to take this medication for up to two
years. Gallstones may recur, however, once the drug is stopped. Obstruction of the
common bile duct with gallstones can sometimes be relieved by endoscopic
retrograde sphincterotomy (ERS) following endoscopic retrograde
cholangiopancreatography (ERCP). Gallstones can be broken up using a procedure
called extracorporeal shock wave lithotripsy (often simply called
"lithotripsy"),which is a method of concentrating ultrasonic shock waves onto the
stones to break them into tiny pieces. They are then passed safely in the feces.

However, this form of treatment is suitable only when there is a small number of
Cholecystectomy (gallbladder removal) has a 99% chance of eliminating the
recurrence of cholelithiasis. Surgery is only indicated in symptomatic patients. The
lack of a gallbladder may have no negative consequences in many people.
However, there is a portion of the population between 10 and 15% who
develop a condition called postcholecystectomy syndrome which may cause
gastrointestinal distress and persistent pain in the upper-right abdomen, as well as a
10% risk of developing chronic diarrhea.
There are two surgical options for cholecystectomy:
Open cholecystectomy is performed via an abdominal incision (laparotomy)
below the lower right ribs. Recovery typically requires 35 days of
hospitalization, with a return to normal diet a week after release and to normal
activity several weeks after release.
Laparoscopic cholecystectomy, introduced in the 1980s,is performed via
three to four small puncture holes for a camera and instruments. Postoperative care typically includes a same-day release or a one night hospital
stay, followed by a few days of home rest and pain medication. Laparoscopic
cholecystectomy patients can, in general, resume normal diet and light
activity a week after release, with some decreased energy level and minor
residual pain continuing for a month or two. Studies have shown that this
procedure is as effective as the more invasive open cholecystectomy, provided
the stones are accurately located by cholangiogram prior to the procedure so
that they can all be removed.


Choledocholithiasis (stones in common bile duct) is one of the complications of

cholelithiasis (gallstones), so the initial step is to confirm the diagnosis of
cholelithiasis. Patients with cholelithiasis typically present with pain in the rightupper quadrant of the abdomen with the associated symptoms of nausea and
vomiting, especially after a fatty meal. The physician can confirm the diagnosis of
cholelithiasis with an abdominal ultrasound that shows the ultrasonic shadows of
the stones in the gallbladder.
The diagnosis of choledocholithiasis is suggested when the liver function blood
test shows an elevation in bilirubin and serum transaminases. Other indicators
include raised indicators of ampulla of vater (pancreatic duct obstruction) such as
lipases and amylases. In prolonged cases the INR may change due to a decrease in
vitamin K absorption. (It is the decreased bile flow which reduces fat breakdown
and therefore absorption of fat soluble vitamins). The diagnosis is confirmed with
either an MRCP (magnetic resonance cholangiopancreatography), an ERCP, or an
intraoperative cholangiogram. If the patient must have the gallbladder removed for
gallstones, the surgeon may choose to proceed with the surgery, and obtain a
cholangiogram during the surgery. If the cholangiogram shows a stone in the bile
duct, the surgeon may attempt to treat the problem by flushing the stone into the
intestine or retrieve the stone back through the cystic duct.
On a different pathway, the physician may choose to proceed with ERCP before
surgery. The benefit of ERCP is that it can be utilized not just to diagnose, but also
to treat the problem. During ERCP the endoscopist may surgically widen the
opening into the bile duct and remove the stone through that opening. ERCP,
however, is an invasive procedure and has its own potential complications. Thus, if
the suspicion is low, the physician may choose to confirm the diagnosis with

MRCP, a non-invasive imaging technique, before proceeding with ERCP or


Treatment involves an operation called a choledocholithotomy, which is the

removal of the gallstone from the bile duct using ERCP, although surgeons are now
increasingly using laparoscopy with cholangiography. In this procedure, tiny
incisions are made in the abdomen and then in the cystic duct that connects the
gallbladder to the bile duct, and a thin tube is introduced to perform a
cholangiography. If stones are identified, the surgeon inserts a tube with an
inflatable balloon to widen the duct and the stones are usually removed using either
a balloon or tiny basket.
If laparoscopy is unsuccessful, an open choledocholithotomy is performed. This
procedure may be used in the case of large stones, when the duct anatomy is
complex, during or after some gallbladder operations when stones are detected, or
when ERCP or laparoscopic procedures are not available.
Typically, the gallbladder is then removed, an operation called cholecystectomy,
to prevent a future occurrence of common bile duct obstruction or other

IX. Preventive
Eat a healthy diet, exercise often, and maintain a healthy weight to reduce your risk
of gallstones.
1.Control Your Weight:

However, avoid rapid weight loss such as occurs with crash diets, as that can
actually trigger gallstones. Weight loss should be slow and steady focus on
losing a pound or two per week until you reach your goal.
In addition, weight cycling frequent weight loss followed by weight gain
can also cause gallstones, so do your best to keep your weight off once you lose it.
Ursodiol (Actigall), usually used to dissolve gallstones, may be prescribed for
people who need to lose weight rapidly, in order to prevent the formation of
gallstones. Similarly, orlistat (Xenical), which is used to treat obesity, may help
prevent gallstones during weight loss by reducing bile acids, which can contribute
to gallstone formation
2.Eat Healthfully and Exercise
Diet and exercise play an important role in gallbladder disease. But to prevent
gallstones, you don't have to subsist on fruits and veggies alone. Here is a rundown
on the good and the bad when it comes to diet, exercise and gallstones:

. Fat tends to get a bad rap, but not all fat is bad.
There are types fats: Monounsaturated fats, saturated fats

Monounsaturated fats, found in

olive oil and canola oil, and omega-3 fatty acids, found in avocados,

canola, flaxseed, and fish oil, may lower the risk of developing
gallstones. Fish oil may be especially beneficial to people with high
levels of triglycerides, as it helps the gallbladder empty.

But stay away from saturated fats found in fatty meats, butter, and
other animal products, as these fats can increase your likelihood of
gallstones and high cholesterol, among other health risks. If you do
eat animal products, choose low-fat alternatives lean chicken
instead of red meat, skim milk and low-fat yogurt instead of whole
milk. Try one of the many healthy butter alternatives (make sure it
does not contain trans fats or saturated fats).

Fiber. Found in whole-grain breads, cereals,

and vegetables, fiber in your diet can help you lose weight and may
prevent gallstones.

Fruits and veggies. There are lots of reasons to eat these wonder
foods, and here's one more: Consuming lots of fruits and vegetables
may prevent gallstones.
Nuts. Peanuts and tree nuts, such as almonds and walnuts, may
prevent gallstones. Plus snacking on almonds is a healthy way to ease
hunger and help you lose weight.
Sugar. Too much sugar in your diet may cause gallstones, so stay
away from sweets, and choose low-sugar food alternatives when
Carbs. Because carbohydrates are converted into sugar in the body,
diets filled with pasta, white bread, and other carbohydrate-rich foods
may increase your risk of gallstones.

Alcohol and coffee:. Studies suggest that moderate consumption of

alcohol and coffee may actually prevent gallstones.
Exercise. Getting regular exercise can help you keep your weight
down, which may prevent gallstones. Thirty minutes, five times a
week is all that is needed to make a difference.
3.Avoid Certain Medications
The following types of medications can also increase your gallstone risk:

Cholesterol-lowering drugs. Some

drugs used to lower blood cholesterol, such as gemfibrozil (Lopid)
and fenofibrate (Tricor), can put you at higher risk of developing
gallstones. That's because these medications increase the amount of
cholesterol released in bile which can lead to gallstone formation
at the same time that they lower blood cholesterol. If you are
taking one of these drugs, talk to your doctor about switching to
another type of cholesterol-lowering medication, since not all
cholesterol drugs have this effect.

Hormone therapy. Hormone

replacement therapy can increase a woman's risk of developing
gallstones since estrogen causes the body to make more cholesterol. If
you are taking hormone therapy or are on high-dose birth control

pills, talk to your doctor about your risk of gallstones, and ask if there
are other hormone medications that may be better for you.