About 10-15% of people in the Western industrialized nations suffer from gallstones. Women are more often affected than men. In persons over the age of 40 years, one in five women and one in ten men have gallstones. Of these, about 20-25% report symptoms related to their gallstones. About two-thirds of persons with gallstones, however, have no symptoms at all. These are called “silent” gallstones.
Experts generally agree that there is no need to treat gallstones unless they cause symptoms, such as colics. The primary option for these patients today is the surgical removal of the gallbladder. Unlike previous open surgery, many patients will be offered the option of laparoscopic (“keyhole”) surgery. There are other non-surgical methods for treating gallstones composed of mainly cholesterol, as is the case with most patients in Europe and North America. One option is oral dissolution therapy, in which stones are dissolved by means of orally administered medication. Some patients may opt for a method known as extracorporeal shockwave lithotripsy, in which externally applied ultrasonic waves pulverize the gallstone.
The choice of treatment method depends in each individual case on the size and composition of the gallstones; function of the gallbladder, as well as on factors such as the patient’s surgical risk and on personal preference.
The most well-known and symptoms caused by gallstones are the so-called biliary colics, which are severe abdominal pains lasting longer than 15 to 30 minutes. The pain is located predominantly in the right upper abdomen but may radiate to the right shoulder and to the back.
Colics often occur after meals that include certain types of food. Although the exact pattern of foods that cause problems can differ widely between individuals, many persons report symptoms following consumption of meals that are particularly high in fat content.
In Europe and North America, gallstones are composed most commonly of cholesterol, with varying proportions of calcium and metabolites (break-down products) of bilirubin (bile pigment). Gallstones form when the bile acids found in the bile can no longer completely dissolve the cholesterol that has been excreted from the liver. This results in precipitation of tiny cholesterol crystals, which form the basis for the development of gallstones.
The principle of oral dissolution therapy is to again dissolve this cholesterol by providing the organism with increased amounts of the water-soluble bile acid ursodeoxycholic acid (UDCA). The bile acid can reverse the process of stone formation and cause already formed stones to dissolve.
Suitable for this type of therapy are patients whose gallstones are predominantly composed of cholesterol. These stones cannot be seen on normal x-ray images but are seen with ultrasound. The maximum diameter of the stones should not exceed 5-10 mm and the gallbladder should be no more than half-filled with stones. The bile ducts must be open in order to prevent a blockage of the bile.
Patients choosing oral dissolution therapy require much patience. Just as it takes a certain length of time for stones to form, their dissolution also requires time. The treatment usually lasts at least nine to 12 months and may take as long as two years. During this time, the bile acid capsules must be taken regularly otherwise no success can be expected. It is best to take the preparation at bedtime. If patients regularly take the medication, up to 70% of stones suitable for this treatment method can be expected to dissolve.
Shockwave lithotripsy is still practiced in a few clinics. Gallstones are fragmented by means of shockwaves that are produced by a generator outside the body and precisely focused on the stone. The stone then fractures into many tiny fragments, which are subsequently flushed away through the common bile duct with the bile. Patients are usually advised to continue treatment with ursodeoxycholic acid in order to dissolve any remaining stone fragments.
The shockwave treatment lasts 30-60 minutes. The breakdown of the stone is monitored with ultrasound. Depending on type, size and number of stones, some patients may require more than one such treatment session.
This method is especially suitable when the gallbladder contains only solitary stones. Stones must not be calcified and their diameter should not exceed two centimeters. The gallbladder must also be functionally intact, the bile ducts must be open and inflammation must be excluded.
If these criteria are met, adequate patient selection results in 60-90% of patients becoming stone free within just a few months. This method is far less agressive than surgery and, as with oral dissolution therapy, the gallbladder remains intact.
Cholecystectomy, the surgical removal of the gallbladder, is currently the most commonly employed treatment for gallstone disease. In most cases, patients are offered laparoscopic (“keyhole”) surgery, which requires several very small incisions instead of one large one. About 100,000 operations of this kind are performed annually in the U.K. The removal of the gallbladder (and any stones it may contain) is among the safest of all surgical procedures. Still, surgery is more stressful and associated with more risk for complications than oral dissolution therapy or shockwave lithotripsy.
If the surgical option is chosen, patients should, whenever possible, decide in favour of laparoscopic cholecystectomy (removal of the gallbladder), which does not require a large abdominal incision and leaves behind only small scars. Conventional open cholecystectomy with large abdominal incision may be unavoidable in complicated situations, such as significant inflammation of the gallbladder or bile ducts, or in patients who had undergone prior abdominal surgeries.