CHOLELITHIASIS

C H O L E L I T H I A S I S / G A L L B L A D D E R S T O N E S
INTRODUCTION
The gallbladder concentrates and stores the bile produced by the liver until the bile is
needed for fat digestion. The formation of gallstones, or cholelithiasis, results from
excessive concentration and crystallization of the compounds in bile. Bile is a solution
of bile acids, cholesterol, phospholipids, proteins, and bile pigment (bilirubin). While
stored in the gallbladder, bile’s concentration increases approximately 10-fold as its
water content is extracted. Factors that raise bile’s cholesterol concentration, promote
crystal formation, or reduce gallbladder motility favor gallstone formation.
TYPES OF GALLSTONES
1. Cholesterol Gallstones
In about 80 percent of cases, the gallstones are composed
primarily of cholesterol, although they also contain calcium
salts and bilirubin. The cholesterol in bile precipitates out of
solution and forms small crystals, which eventually coalesce to
form stones. The stones can be as small as a pea or as large as a
Ping Pong ball. Some people tend to form many small stones,
while others may form only one or two large ones. Cholesterol
gallstones often develop because the bile concentrate thickens
and forms a sludge that cannot be easily expelled by
gallbladder contraction. Biliary sludge frequently develops
after rapid weight loss, gastric bypass surgery, and long term
total parenteral nutrition and also occurs during pregnancy.
2. Pigment Gallstones
Pigment stones are more common in Asian
countries. Pigment stones are primarily made up
of the calcium salt of bilirubin (calcium
bilirubinate). They often develop as a result of
bacterial infection, which alters bilirubin and
causes it to precipitate out of bile and form
stones. Conditions associated with pigment stone
formation include biliary tract infections,
pancreatitis, and red blood cell disorders, such as
sickle-cell anemia. Pigment stones may form in
either the gallbladder or a bile duct. Unlike the
crystalline cholesterol stones, pigment stones are
soft and easily crushed
SYMPTOMS
About 85 percent of gallstones are asymptomatic and are discovered accidentally while
testing for other conditions. Many people experience an aggressive course of illness
with recurring symptoms. The pain is steady and severe and may last for several minutes
or several hours. Although the pain is usually located in the upper abdomen, it may
radiate to the chest or to the back.
1. Nausea, vomiting, and bloating may also be present.
2. Symptoms usually develop after meals, especially after eating fatty foods. Pain may
also occur during the night and awaken a person from sleep.
C O M P L I C AT I O N S
If a gallstone remains lodged in the cystic duct, it can

obstruct bile flow to the duodenum and cause cholecystitis
—distention and inflammation of the gallbladder.
Cholecystitis can lead to infection or to more severe
complications, including perforation of the gallbladder,
peritonitis, and fistulas. If gallstones obstruct the common
bile duct, they can block bile flow from the liver and lead to
jaundice or damage to liver tissue. An impacted stone
within the bile ducts may lead to infection and the condition
known as bacterial cholangitis, which causes severe pain,
sepsis, and fever and is often a medical emergency.
Gallstones can block the pancreatic duct as well.
RISK FACTORS
•Ethnicity
Although the genetic factors related to gallstone formation are not yet clear, ethnicity strongly influences gallstone formation.
•Aging
Because gallstones cannot dissolve spontaneously, gallstone prevalence increases with age. Moreover, bile composition tends to change
with aging: the cholesterol concentration increases while bile acids decrease, leading to a greater cholesterol crystallization
•Gender
The incidence of gallstones in women is nearly three times that in men during the reproductive years, although it falls to a similar level
after menopause. The reason for the gender difference is that estrogen alters cholesterol metabolism and causes an increased secretion of
cholesterol into bile.
•Pregnancy
Some women experience their first gallstone symptoms during pregnancy. Gallstone risk is increased in pregnancy due to hormonal
changes
•Obesity and Weight Loss
Obesity is associated with increased cholesterol synthesis in the liver, leading to a greater release of cholesterol into bile. Gallstones
frequently develop as a result of rapid weight loss, occurring in about 25 percent of obese persons on very-low-calorie diets and in as many
as half of individuals who undergo gastric bypass surgery. Dieting increases the secretion of cholesterol into bile and may also decrease
gallbladder motility.
•Other Risk Factors
Long-term total parenteral nutrition usually reduces gallbladder motility, increasing the development of biliary sludge. Some medications
may have similar effects. High triglyceride levels in blood are also associated with increased gallstone risk, as are hyperinsulinemia, insulin
resistance, and diabetes mellitus
T R E A T M E N T
• Asymptomatic gallstones generally do not require treatment. Gallstones that

cause symptoms or complications are usually treated by gallbladder surgery or
by nonsurgical procedures that dissolve or fragment the stones.
•Surgery
Gallbladder removal, or cholecystectomy, is the primary treatment for patients

with recurring gallstones. The preferred surgical approach is a laparoscopic
method. The procedure takes only one or two hours, and many patients are
discharged on the same day as the surgery. In patients with complications that
make organ removal difficult, open cholecystectomy may be performed. Once the
gallbladder has been removed, the common bile duct collects bile between meals
and releases it into the duodenum at mealtimes. Most patients have no problems
after they recover from surgery, although some may experience diarrhea,
abdominal pain, and other gastrointestinal symptoms. The diarrhea may result
from an increased amount of bile in the large intestine, which has a laxative effect
•Nonsurgical Procedures
Nonsurgical methods are used primarily in patients who have small cholesterol stones and
transient conditions associated with gallstone formation. The gallstones can be treated by oral
intake of ursodeoxycholic acid (ursodiol), a bile acid that reduces cholesterol secretion by the
liver and eventually causes the cholesterol crystals in gallstones to dissolve. Ursodeoxycholic
acid must be used for 6 to 12 months and is best suited for stones that are 5 millimeters (about
1/4 inch) in diameter or smaller. Recurrence rates after dissolution are as high as 50 percent.
Cholesterol gallstones can be fragmented using shock-wave lithotripsy, a procedure that is
also used to fragment kidney stones. Recurrence of gallstones has been reported in up to 44
percent of patients using this procedure.
MEDICAL NUTRITION THERAPY
Gallstones are more prevalent in low-fiber, high-fat, westernized diets. Consumption of

large amounts of animal protein and animal fat, especially saturated fat, and a lack of
dietary fiber, promote gallstone development. There also may be some benefit in replacing
simple sugars and refined starches with high-fiber carbohydrates. Individuals consuming
refined carbohydrates have a 60% greater risk for developing gallstones, compared with
those who consumed the most fiber, in particular insoluble fiber. Thus plant-based diets may
reduce the risk of cholelithiasis. Weight cycling (repeatedly losing and regaining weight),
fasting, and very-low-calorie diets increase the likelihood of cholelithiasis. Along with
weight reduction, some evidence indicates that physical activity reduces the risk of
cholecystitis. In cholecystitis, MNT includes a high-fiber, low-fat, plant-based diet to
prevent gallbladder contractions. After surgical removal of the gallbladder, oral feedings
can be advanced to a regular diet as tolerated.

CHOLELITHIASIS

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C H O L E L I T H I A S I S / G A L L B L A D D E R S T O N E S

If a gallstone remains lodged in the cystic duct, it can

• Asymptomatic gallstones generally do not require treatment. Gallstones that

Gallbladder removal, or cholecystectomy, is the primary treatment for patients

Gallstones are more prevalent in low-fiber, high-fat, westernized diets. Consumption of

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