Cholelithiasis (gallstones)
 
The gallbladder serves the purpose of delivering bile into the intestine when we ingest a fatty meal.  Through various mechanisms stones can form inside the gallbladder in some individuals. Many people go through life with stones in their gallbladders without ever having any symptoms and the gallstones are discovered only in an incidental study or autopsy.  In others, however, stones move around inside the gallbladder and get pushed into the outlet of the gallbladder. If the stones are too large to pass through, the gallbladder keeps contracting, produces colicky pain while it gets filled with more fluid and a vicious cycle of distention and pain occurs.
 
Occasionally, infection sets in on top of this colicky situation and patients become sicker with fever and chills; we call this acute cholecystitis. In some patients, the stones pass out of the gallbladder and then get stuck at the end of the common bile duct which drains all bile from the liver and merges with the pancreatic duct. This complication, named choledocolithiasis, can result in jaundice and pancreatitis.  
 
The only solution for symptomatic gallstones, meaning recurrent colicky pain in the right upper abdomen associated with gallstones, is the removal of the gallbladder also known as cholecystectomy.  As opposed to kidney stones that can be shattered from the outside and urinated out, with gallstones the gallbladder itself is ill and will keep producing stones forever.  Interestingly, the gallbladder seems to be another “spare” part in the body.  Surgeons have been doing cholecystectomies for a century and no ill effects have been reported as a result of a missing gallbladder.
 
A totally different scenario is the patient with pain in the right upper abdomen who undergoes studies, typically and ultrasound, and is found to have no stones.  Usually, the next step is to obtain an HIDA scan which is a study of the contractility of the gallbladder in response to a medicine that is injected intravenously.  
 
Unfortunately, the results of these studies cannot predict if the surgery will successfully relieve the pain in patients whose ultrasounds show no evidence of gallstones.  Not only may these patients continue to have the same type of pain but they also seem to develop complications of surgery more often than patients who do have stones.  Therefore, our general rule is to offer cholecystectomy only to those patients with either confirmed or highly suspected gallstones, even if they are very small “sludge” producing stones instead of typical stones.
 
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