Gallstones: why do they cause pain and discomfort?

Most gallstones are not dangerous, but they can become dangerous, and if left untreated can pose a severe threat to your health. Gallstones can pose a danger if they block the exit of gallbladder and the flow of bile through it. In this instance, you may get an infection within the gallbladder. This is what is known as cholecystitis which can be either acute or chronic (long-standing).

When gallstones leave the gallbladder they usually go via the bile duct. If gallstones get stuck in the bile duct this can lead to jaundice. Jaundice means yellowing of the eyes and the production of dark yellow urine. Gallstones can also irritate the pancreas and cause pancreatitis. Both pancreatitis and jaundice can be serious, life-threatening illnesses.

In rare instances, gallstones can go into the bowel and cause blockage, meaning food cannot pass through. When this happens, patients would present with abdominal pain and vomiting which should be treated as a serious condition. How gallstones should be treated has to be decided with your specialist, who will consider your symptoms, scan results and blood test results before making any recommendations.

The pain from gallstones usually presents in the upper part of the tummy, close to the breastbone or just below the right ribcage. The pain is usually spasmodic or colicky which means it comes and goes in waves. Gallstone pain can sometimes move to the back towards the right shoulder blade too. Pain may be associated with vomiting or intolerance to fatty food. Gallstone pain may be avoided by avoiding fatty foods such as fried food, butter, cheese and dairy products with a high fat and cholesterol content.

For more information on what factors contribute to gallstones in families, visit this news article.

Surgery is required for some conditions where gallstones are causing problems. Surgery is most commonly required to prevent future problems which the gallstones may cause. Surgery may also be required when the patient presents with symptoms from gallstones such as pain, vomiting, or intolerance to fatty food. Gallstone surgery may also be carried out when gallstones cause complications such as pancreatitis or obstructive jaundice.

Gallstones are not removed on their own but are removed along with the gallbladder. If one does not remove the gallbladder, gallstones are likely to form again as the gallbladder is unable to expel bile. Therefore, gallstone surgery is accompanied by removal of the gallbladder.

Gallstone surgery is commonly performed as laparoscopically (keyhole surgery), which means small incisions are made on the abdomen or tummy. This is called a laparoscopic cholecystectomy. Laparoscopic cholecystectomy is usually done as a day-case procedure. You may be required to stay in longer than a day depending on your physical condition, whether you have other health problems or if you have any complications from the gallstones.

The most common problems experienced by patients after laparoscopic choleocystectomy include mild shoulder pain (from CO2 gas used during the procedure) and wound infection (signs of possible infection include increasing pain, swelling or redness and pus leaking from the wound – see your GP if you develop these symptoms). Much rarer complications, present in fewer than 1% of patients, include bleeding, bile leaks and deep vein thrombosis (although the latter is generally restricted to those already at higher risk of developing blood clots). Injuries to the bile duct or blood vessels are possible but are exceedingly rare.

The truth is we do not really know exactly what causes Inflammatory Bowel disease but we do know that some things play a role.

Genetics

We know that if someone in your family has inflammatory bowel disease it is more likely that other members of your family will develop inflammatory bowel disease.  This suggests that some people carry something in their genes which pre-disposes them.  The strongest example of this is in identical twins.  In identical twins, if one has Crohn’s disease, two-thirds of the other twins will also develop Crohn’s disease. If a member of your family has inflammatory bowel disease, then the chance of you developing Crohn’s disease or ulcerative colitis is around 10%.

We now know a lot about the genes which increase your risk of developing inflammatory bowel disease.  There are lots of genes (more than 100) each of which can play a small role in increasing your risk.  These genes affect many different systems in your body and it reflects the complicated nature of inflammatory bowel disease.  No one gene causes inflammatory bowel disease but your risk is increased if you carry lots of these particular genes, each of which causes a small increase in risk.  The surprising thing is that many of these genes are shared with other diseases which you might not expect.  Other autoimmune diseases (diseases where the body’s immune system plays a role in the development), such as diabetes and rheumatoid arthritis share some of the genes.  Unfortunately, because the genes are so complicated we cannot yet test individuals to see whether or not they will develop inflammatory bowel disease.

Environmental factors

For most people genetics only plays a small role in the development of inflammatory bowel disease.  We think the rest is due to something in the environment but we do not really know what that is.  We do however have some ideas.

• Diet: We do not really know what it is in the diet which might cause inflammatory bowel disease.  We do however, think that a poor diet with lots of processed foods and high sugar and fat may be associated with inflammatory bowel disease.  For this reason, along with many other reasons, you should try and eat a healthy diet with lots of fruit and fibre and non-processed foods.
• Bacteria in the bowel: We each carry millions of bacteria in our bowel.  Each of us has a unique pattern of bacteria which we call our bacterial flora.  We know that in patients with inflammatory bowel disease the bacterial flora changes.  Patients with inflammatory bowel disease tend to have fewer kinds of bacteria in the bowel and sometimes have more of a particular kind present.  However, we do not really know if this causes the development of the disease or whether it is as a result of having the condition.  This is a huge area of research and hopefully we will know more in the years to come.
• Smoking: We know that if you smoke you are more likely to develop Crohn’s disease.  We also know that if you  smoke, the treatment that you receive for Crohn’s disease is less likely to work.  For this reason we tell all patients with Crohn’s disease that they must stop smoking.  It is another good reason why smoking is not good for you.  Unusually, smoking does seem to reduce your risk chances of getting ulcerative colitis.  However, this is outweighed by all the damage that smoking can cause to your heart and lungs, so we would never advise a patient to start smoking for their ulcerative colitis.
• Psychological stress: Lots of patients with inflammatory bowel disease tell us that their disease is made worse by stress.  Some patients also think that they developed inflammatory bowel disease after particular periods of stress.  However, the situation is always very complex as everybody’s life is stressful and it is often easy to remember a particular time as being stressful looking back when you were having a flare or after developing a disease.  We do, however, think that on balance stress probably does play a role.  But the other challenge is that with modern living, it is extremely difficult to remove all the stress from our lives, so this is rarely something we can use as a treatment.
• Living in the modern world: We think that Inflammatory Bowel disease is more common in developed countries than in developing countries.  The cause for this is not known.  Lots of different things have been suggested as possibly being the cause for this difference.  Some people have proposed that perhaps refrigerated foods, or micro particles which are found in substances such as toothpaste, or sulphur containing foods might be a risk factor.  The reality is, however, that we do not really know if any of these are true as it has been very difficult to prove.

Gallstones can be treated without surgery, but only if they meet certain criteria. In some cases, gallstones can be treated with medicines such as ursodiol or chenodiol, which are able to thin the bile and allow gallstones to dissolve. While these medications can be effective and are generally well tolerated by patients, medical treatment of gallstones is limited to people whose stones are small and made of cholesterol. Additionally, these drugs can take over two years to work, and gallstones may still return after treatment ceases.

Another non-surgical method is extracorporeal shock-wave lithotripsy (ECSWL), which uses shock waves to break up or fragment gallstones; this method, however, is only effective for solitary gallstones that are less than 2 cm in diameter. If a patient has multiple gallstones, even when the stones are fragmented, a diseased gallbladder may not expel the fragments. Generally this treatment is not recommended.

From the limited evidence available, changes to your diet and losing weight (if you are overweight) may help prevent gallstones. Since cholesterol appears to play a role in the formation of gallstones, it is advisable to avoid eating too many foods with a high saturated fat content. A healthy, balanced diet is recommended, including plenty of fresh fruit and vegetables, and wholegrains.

There’s also some slim evidence that regularly eating nuts, such as peanuts or cashews, can help reduce your risk of developing gallstones.

Additionally, being overweight, particularly being obese, increases the amount of cholesterol in your bile, which increases your risk of developing gallstones. You should control your weight by eating a healthy diet and taking plenty of regular exercise. However, you should avoid low-calorie, rapid weight loss diets, as there’s evidence that they can disrupt your bile chemistry and increase your risk of developing gallstones. As such, a more gradual weight loss plan is recommended.