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I'm Stoned!

"Gallstones, that is!"
By: Marc Evans Abat, MD, FPCP, FPCGMI'm Stoned!

No, this is not about living in an era of sweet smoke and getting high!  Rather than feeling like floating on air and being surrounded by pretty colors and weird visions, being “stoned” in this situation can be downright unpleasant, painful and even dangerous to your health! 

But before we talk about gallstones, let us talk aboutthe gallbladder and bile first.  The gallbladder is that small sac connected and snugly placed under your liver, near the right upper quadrant of your abdomen.  Bile (the yellow fluid used to make “papaitan” bitter), is secreted by the liver and flows into the gallbladder for storage.  The bile in the gallbladder is not the same as the initially secreted bile from the liver. Bile contains cholesterol, bile salts (produced also from the liver) and bile pigments (breakdown products of hemoglobing—the pigment in blood), plus water and electrolytes. 

Now to the “gritty” part (pun intended).  How do gallstones (or technically called cholelithiases) form?  The first key word is supersaturaiton.  This is the state wherein there is really a concentrated amount of either cholesterol or bile pigments in the bile, making prone to formation of crystals.  This can happen if there is too little water in the bile (e.g. you drink too little water or take too much salty food), or if there is an excess amount of cholesterol secreted (e.g. if your blood cholesterol levels are too high), or you produce too much bile pigments (e.g. your red blood cells rupture too easily like in certain blood diseases).  Once a certain point is passed, the propensity of cholesterol to stay dissolved in bile decreases, and cholesterol crystals start to form.  These initially get mixed in the gallbladder mucus, forming a thick sludge.

So who gets easily “stoned”?  Females, obese, pregnancy, and those who lose weight rapidly due to caloric and fat restriction (e.g. from dieting, those who underwent gastric bypass surgery) can develop gallstones.  Certain drugs may increase gallstone risk.  Those taking estrogen hormones develop stones due to increased excretion of cholesterol in the bile.  This is the same also for cholesterol-lowering medications called fibrates (not to be confused with dietary fiber—they’re not the same).  And there are some people who have a genetic risk for gallstone formation—either due to excessive cholesterol production or decreased lecithin production (lecithin helps keep cholesterol dissolved) and secretion. 

Most patients with gallstones do not have symptoms.  The likelihood of developing symptoms and complications in those asymptomatic is around 1-2% per year.  These can co-exist with other diseases (like acid-related gastritis or reflux) and are often mistaken to be the cause of symptoms like abdominal bloating or pain.Symptoms from gallstones are usually unpredictable in timing.  Pain usually starts within an hour of a fatty meal.  It is crampy and colicky, and is localized to either the sikmura or epigastric area, or the right upper abdomen, often with radiation to the lower tip of the right shoulder blade.

Acute calculouscholecystitis is the distension inflammation of the gallbladder resulting from the gallstone blocking the outlet.  This may present with fever and tenderness of the right upper quadrant of the abdomen.  Progressive infection of the gallbladder can lead to empyema, or accumulation of pus.  Ascending cholangitis can also happen as a complication, when the infection spreads into the biliary tree.  Pancreatitis, or inflammation of the pancreas can happen if the gallstones gets out of the gallbladder and eventually blocks the duct that is also connected with the pancreas.

Those with gallstones but do not have any symptoms, in general, need to be observed only, as the risks of the complications with interventions is higher than that of developing symptoms.  Those who need elective removal of the gallbladder are those who expect higher rates of developing complications (e.g. those with large gallstones, or those with calcified gallbladders).  Medical management of gallstones with no symptoms is by giving a dissolution agent like ursodeoxycholic acid.  This helps by reducing the saturation of cholesterol in the bile, thereby gradually dissolving cholesterol gallstones.  However, this needs prolonged treatment (as in months) and may be less than 50% effective. 

So how do we avoid getting gallstones in the first place?  Avoid rapid weight loss diets which can lead to stone formation.  Even in those dieting, a small amount of fat is needed, especially to provide lecithin to dissolve cholesterol in bile.  Avoid becoming dehydrated which may excessively decrease the water content of bile.  Controlling your cholesterol levels is important since cholesterol is the key component.

So if you do get “stoned”, as in have gallstones, help is only a stone’s throw away!

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