A large population-based ultrasound study on prevalence of gallstones defined Kashmir as an endemic zone for gallstone disease [Khuroo MS, et al. Prevalence of biliary tract disease in India: a sonographic study in adult population in Kashmir. Gut 1989;30: 201–205]. Overall prevalence of gallstones was 6.12 per cent (3.07 percent in adult men and 9.6 percent in adult women). One in sixteen adults, one in 10 women and one in 3 women above 50 years of age have gallstones. Of great importance was the finding that only one in 20 (5%) subjects with gallstone had symptoms related to disease, while gallstones were silent (caused no symptoms) in over 95 percent subjects. These data explain the observation of many radiologists (including me) in Kashmir of finding gallstones in patients referred for ultrasound abdomen for varied complaints. However once gallstone is detected on ultrasound, patients get worried and look for solutions including (i) local-healer’s help (many claim to suck the stones from gall bladder or kidneys); (ii) drug treatment & (iii) ultimately surgery. What is gallstone disease, how do stones form, what problems gallstones can cause and what are silent stones- are questions which everybody is curious to know? Also what should one do if a gallstone is detected on your next ultrasound examination and how to proceed rationally in this regard?
Gallbladder is a small bag placed underneath the liver in the right upper abdomen. Bile (greenish yellow juice produced by liver) reaches the gall bladder through bile ducts and this juice is stored and concentrated (90% of water is taken out of it) in gall bladder. When we eat, gall bladder contracts to push bile juice in to the intestines to help digestion. Gall bladder stones are of 3 main types (i) cholesterol stones, (ii) black pigment stones, (iii) brown pigment stones. Cholesterol stones are the commonest type. Bile juice has 3 constituents namely bile salts (acids), cholesterol and phospholipids and these three are normally in perfect ratio to keep cholesterol in solution. In certain circumstances bile acids in bile may be reduced in amount or cholesterol may be increased and because of this, cholesterol cannot be kept in solution and may crystallize (microcrystal disease) and form thick mud (gallbladder sludge). Later the cholesterol may nucleate and form small and later larger stones. The abnormalities of bile constituents occur due to abnormalities in liver enzymes forming these and these enzymes are under genetic control and certain genetic abnormalities causing bile composition defects are common in certain populations including Kashmir. Thus gall stone disease may present in any of these 3 ways (microcrystal disease, Gallbladder sludge and gallstones).
Gallstone disease may be silent (cause no symptoms). In fact this is how gallstones stay throughout the life of most subjects and these people die of unrelated cause and gall stones may be detected on autopsy for the first time. Once symptoms occur, most common is biliary colic (short lasting severe pain right upper abdomen with vomiting) and often needs pain killer in to the arm vein. If a gallstone blocks the gallbladder outlet, one gets episode of acute cholecystitis (inflammation of gallbladder causing pain, fever and tender gall bladder lump). This may be complicated by gallbladder rupture which can cause serious consequences. Gallbladder disease may be complicated by acute pancreatitis (inflammation of pancreatic gland) and this disease may also lead to serious consequences. Gallstones are associated with gallbladder cancer in high risk population like ours. If gallstone slips in to the duct, it can block it causing jaundice.
Ultrasound is the most accurate tool to detect gallstone disease (microcrystal, sludge and stones) and evaluate its consequences. It can evaluate size and number of stones, define gallbladder condition and imagine pancreas and other related organs like liver etc. Once gallstones cause symptoms as defined above (colic, cholecystitis, pancreatitis etc), most clinicians believe that gall bladder should be removed along with stones (cholecystectomy). Laparoscopic cholecystectomy is the standard procedure and has replaced open (surgical) cholecystectomy. Patients with microcrystal disease and sludge are amenable to drug treatment and do not need surgery. Bile is made thinner by giving bile acids by mouth and the cholesterol stays in solution by increasing bile acid content of bile.
Patients with silent stones are the largest group and management of such patients needs careful evaluation. A small significant group of silent or mildly symptomatic stones are good for drug therapy. Such patients should fulfil following conditions: (i) healthy functioning gall bladder; (ii) cholesterol stones with no calcium content and (iii) individual stone size less than 0.6 cm. This can be evaluated by: (i) “functional ultrasound gallbladder study” to evaluate gallbladder function and stone size and (ii) plain x-ray abdomen & a single non-contrast CT gallbladder film to assess gallstone calcium content. If supportive, drug therapy (bile acids) in this group of patients causes stone dissolution in high percentage of patients. Remaining patients with silent gallstones usually need observation and cholecystectomy is advised once symptoms (colic or cholecystitis) develop. This opinion is based on the observation that most of silent gallstones shall stay silent over long periods of time and may not need any intervention. However a certain group of patients with silent gallstones may become symptomatic in high percentage of patients and prophylactic (to prevent future potential complications) cholecystectomy may be advised under such circumstances. These include patients who are obese and have comorbid illness like heart and lung disease or diabetes or women who like to have another baby in the near future. Some clinician’s advice prophylactic cholecystectomy because of fear of gallbladder cancer and this opinion may hold ground in communities with high prevalence of gallbladder cancer.
Dr. Naira Sultan Khuroo
MBBS (KU), Fellowship Medical Imaging & Radiology (KFSH & RC Riyadh, KSA), Fellowship Fetal Medicine Ultrasound (Fetal Medicine Foundation UK).
Former Fellow Body Imaging, King Faisal Specialist Hospital& Research Centre, Riyadh, KSA.
Consultant Radiologist Digestive Diseases Centre Dr. Khuroo’s Medical Clinic, Sector 1, SK Colony Qamarwari, Srinagar, Kashmir, J&K, 190010 India.
Medical Registration: i. J&K Medical Registration Council-9303 Dated Sept 8th 2006, ii. Saudi Council Health Specialties License Number 301 Sept 14th 2000.