When do you need to have gallstones removed?
All gallstones that cause discomfort must be removed. The typical symptoms appear suddenly:
- Localization of pain in the right upper abdomen
- Radiating pain in the back and arms
- Pain in the right shoulder
Which examinations are necessary before gallstones are removed?
After a physical examination, an ultrasound examination of the gallbladder and bile ducts may be carried out, and blood may also be drawn. If there is evidence of a disease of the esophagus, stomach, or duodenum, a gastroscopy can be performed.
What happens before a gallstone removal?
Digestion activates the gallbladder. In patients with a painful gallbladder, food can make symptoms worse and trigger additional pain attacks. It is therefore recommended that patients with acute gallstone symptoms refrain from eating.
Anticonvulsants help against the uncontrolled painful contraction of the gallbladder. The two common drugs are called N-butylscopolamine and nitrate. In addition, doctors also use classic pain medication from the group of non-steroidal anti-inflammatory drugs (Diclofenac or indometazine are preferred here). For very severe pain, opiates such as pethidine and buprenorphine are required.
If the gallstones cause inflammation, there is always a risk of additional bacterial inflammation. Antibiotics are part of standard therapy for patients with acute symptoms.
Not everyone has to have their gallstones removed. In some studies, gallstones are a secondary finding. Randomly discovered stones can usually be left.
How are gallstones removed?
Depending on the size, location, and nature of gallstones, there are different therapeutic measures. Gallstones can be removed using the following procedures:
- Surgical removal of the entire gallbladder (cholecystectomy) either open or laparoscopic
- Removal using a flexible tube via the mouth (ERCP)
- Medicated with ursodeoxycholic acid
Surgical gallbladder removal
The patient is under general anesthesia during the procedure. In the most preferred minimally invasive laparoscopic procedure, the doctor inserts surgical instruments through four small holes in the abdomen. She pushes a camera into one of the holes to see the operating field in the patient's body. The intervention has few complication risks, and only small scars remain.
Alternatively, the gallbladder can also be removed surgically using a larger incision at the costal margin. The procedure is technically easier but is more often associated with pain and slow recovery. It is therefore only the second choice for therapy, but is necessary in some cases (for example, if adhesions have already occurred in the area as a result of previous operations).
ERCP (endoscopic retrograde cholangiopancreatography)
The patient is not conscious during this procedure. As with gastroscopy, the doctor inserts a multifunctional tube (endoscope) through the mouth. A video camera is attached to its end for orientation. The doctor continues to push the tube through the esophagus and stomach into the duodenum.
There is a mucosal fold (Papilla Vateri) here, which has a connection to the pancreas and bile duct. Gallstones are located behind this mucosal fold and can be found with an X-ray. With small stones, it is sufficient to enlarge the opening of the mucosal fold (papillotomy). Then the stones fall into the duodenum and the patient excretes them. Alternatively, the stones can be caught in the hose with a small basket or broken up with a laser.
ERCP is often preceded by surgical removal of the gallbladder. If gallstones have appeared that have led to symptoms such as severe biliary colic or jaundice, after the stones have been removed, for example by an ERCP, an additional surgical removal of the gallbladder is carried out. The reason for this is the extremely high risk of recurrence and the high complication rate for symptomatic gallstones (e.g. severe inflammation of the pancreas, wall breakthrough of the gallbladder).
Therapy with ursodeoxycholic acid serves to dissolve small cholesterol stones. Ursodeoxycholic acid is a synthetically produced bile acid. The exact mechanisms of action of the drug are not understood and only partially proven. It may suppress the body's production of statins and also inhibit cholesterol absorption via the intestine.
For whom is which method suitable?
Patients with stones in the gallbladder
This group of patients is only recommended to remove the gallbladder if the stones have caused discomfort. Asymptomatic stones that are discovered as a coincidence in the gallbladder and that have not led to problems with the bile duct are not in themselves a reason for removing the gallbladder. As soon as symptoms such as colic or jaundice appear, the gallbladder should be removed.
The goals of removal are:
- To prevent future pain attacks from the gallstones
- To prevent complications
- To prevent gallbladder cancer (in high-risk patients)
Complications from gallstones can include inflammation of the pancreas, blood poisoning, pus accumulation, or a hole in the gallbladder wall (perforation). These complications can be acutely life-threatening. An inflamed gallbladder is removed within 24 hours of hospital admission. The procedure can also be performed on pregnant women.
Patients with stones in the bile duct
The method of choice here is endoscopic retrograde cholangiopancreatography (ERCP), which lowers the risk of pancreatitis. ERCP occurs with simultaneous inflammation of the bile duct within 24 hours after hospital admission. The procedure can also be performed on pregnant women.
Patients with stones in the gallbladder and bile duct
All stones have to be removed. Doctors speak of "therapeutic splitting" because the gallbladder is removed and an ERCP is also performed. The order of the interventions is variable. They can also be done at the same time.
Patients with small cholesterol stones
In individual cases, doctors use ursodeoxycholic acid to dissolve gallstones. The drug is not a standard today because it only works for 60 percent of patients. In addition, many patients get new gallstones after therapy. Ursodeoxycholic acid is an option for patients with multiple gallstones under ten millimeters that do not contain lime. They are not visible on the x-ray. A functional gallbladder is a prerequisite for therapy.
Can gallstones be removed on an outpatient basis?
Some hospitals offer the removal of gallstones or the gallbladder and ERCP as an outpatient procedure. This is only possible for selected patients and after careful preparation, and structured follow-up plans. In most cases, however, an outpatient removal of the gallbladder is not possible and, above all, is not advisable. However, the duration of the hospital stay can be very short, especially with a laparoscopic procedure. However, monitoring directly after an operation in the abdominal cavity is important. Complications can always occur, and the hospital can react quickly.
On the other hand, an outpatient ERCP for purely diagnostic purposes can usually be carried out. In any case, it is advisable to weigh the options well with an experienced doctor beforehand.
Good to know
According to studies, around a third of patients would have liked to be admitted to the hospital after an outpatient procedure.
How can you prevent gallstones?
There are generally three principles for avoiding cholesterol-type gallstones:
- Regular physical activity
- Needs-based nutrition
- Maintaining a balanced body weight
These measures generally help to lower cholesterol and come from obesity therapy. There are only a few studies that examine these three measures specifically for gallstones, but they generally indicate protective effects.
Food to prevent cholesterol gallstones
|Refined sugar||Increases the risk of gallstones|
|Vegetable oils||Lower the risk of gallstones|
|Nuts||Reduce the risk of gallstones|
|Unsaturated fatty acids||Reduce the risk of gallstones|
|Saturated and trans fatty acids||Increase the risk of gallstones|
|Vitamin C as a dietary supplement||Lowers the risk of gallstones|
|Magnesium||Lowers the risk of gallstones (men only)|
|Fruits and vegetables||Reduce the risk of gallbladder removal (women only)|
Doctors usually do not recommend drug therapy for post-treatment of stone problems. There is weak evidence that statins have protective effects. They are used in selected patient groups. The use of statins can be useful, for example, for:
- Stone ailments in the family
- Lack of exercise
Ursodeoxycholic acid is recommended for overweight patients, combined with a strict diet or (if all other weight loss measures have been exhausted) weight loss surgery. In these patients, ursodeoxycholic acid can at least partially reduce the risk of gallstones.
Jenssen, C., & Bauer, G. (2016). Choledocho-und CholezystolithiasisGallstone disease. Der Gastroenterologe, 11(4), 283-294. Downloaded on 28.07.2018 from https://link.springer.com/article/10.1007/s11377-016-0082-8
Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften. AWMF – Leitlinien. Langfassung der Leitlinie. Diagnostik und Therapie von Gallensteinen. Register number 021 – 008. Downloaded on 28.07.2018 from https://www.awmf.org/uploads/tx_szleitlinien/021-008l_S3__Gallensteine-Diagnostik-Therapie_2018-04.pdf