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HOW SERIOUS ARE GALLSTONES AND GALLBLADDER DISEASE?

Asymptomatic gallstones seldom lead to problems. Death from even

symptomatic gallstones is very rare, accounting for only 0.2% of

annual deaths in the United States. Serious complications are rare

and, if they occur, usually develop from stones in the bile duct or

after surgery.

However, gallstones, can cause obstruction at any point along the

ducts that carry bile and, in such cases, symptoms can develop.

In most cases of obstruction, the stones block the cystic duct, which

leads from the gallbladder to the common bile duct. This can cause

pain, infection, and inflammation.

About 10% of patients with symptomatic gallstones also have stones

that pass into and obstruct the common bile duct (called

choledocholithiasis).

Complications of Acute Cholecystitis (Gallbladder Inflammation)

The most serious complication of acute cholecystitis is infection

that spreads to other parts of the body (septicemia). This can be

life-threatening. Symptoms include fever, rapid heartbeat, fast

breathing, and mental confusion.

Among the conditions that can lead to septicemia are the following:

Gangrene or Abscesses. If acute cholecystitis is untreated and

becomes severe, inflammation can cause abscesses or destroy enough

tissue in the gallbladder (called necrosis) to lead to gangrene.

Perforated Gallbladder. About 1% to 2% of persons with acute

cholecystitis have a perforated gallbladder, which is a life-

threatening condition. The risk for perforation increases with a

condition called emphysematous cholecystitis, in which gas forms in

the gallbladder. This condition is most common in people with

diabetes.

Empyema. Pus in the gallbladder (called empyema) occurs in 2% to 3%

of patients with acute cholecystitis. Abdominal pain is usually

severe and is typically present for more than seven days. The

physical exam is not distinctive. The condition can be life-

threatening, particularly if the infection spreads to other parts of

the body.

Both perforation and empyema require prompt surgery. These

complications can be avoided, however, by seeing a physician as soon

as gallbladder symptoms occur.

Complications from Choledocholithiasis (Stones in the Common Bile

Duct)

When gallstones lodge in the common bile duct (choledocholithiasis)

instead of the gallbladder, serious complications can occur.

Infection in the Common Bile Duct (Cholangitis). Infection in the

common bile duct (cholangitis) from obstruction is common and

serious. Those at highest risk for a poor outlook also have one or

more of the following conditions:

Kidney failure.

Liver abscess.

Cirrhosis.

People older than 50 are also at higher risk.

If antibiotics are administered immediately, the infection clears up

in 75% of patients. If cholangitis does not improve, the infection

may spread and become life-threatening. Either surgery or a procedure

known as endoscopic sphincterotomy is required to open and drain the

ducts.

Pancreatitis. Choledocholithiasis is responsible for most cases of

pancreatitis (inflammation of the pancreas), a condition that can be

life-threatening. The pancreatic duct, which carries digestive

enzymes, joins the common bile duct right before it enters the

intestine. It is therefore not unusual for stones that pass through

or lodge in the lower portion of the common bile duct to obstruct the

pancreatic duct.

The pancreas is located behind the liver and is where the hormone

insulin is produced. Insulin is used by the body to store and utilize

glucose.

Gallbladder Cancer

Gallstones are present in about 80% of people with gallbladder

cancer. This cancer is very rare, however, even among people with

gallstones. Certain conditions in the gallbladder pose a higher than

average risk for cancer:

Porcelain Gallbladders. People with gallstones and so-called

porcelain gallbladders have a very high risk for cancer. (In this

condition, the gallbladder walls have become so calcified that they

look like porcelain on an x-ray.) Whether gallstones themselves cause

the cancer or whether some factor in bile is responsible for both

conditions is unknown. One study demonstrated that gallbladder

removal reduced the likelihood of bile duct cancer, suggesting that

gallstones themselves were responsible.

Gallbladder Polyps and Primary Scerlosing Cholangitis. Polyps

(growths) are sometimes detected during diagnostic tests for

gallbladder disease. Small gallbladder polyps (up to 10 mm) pose

little or no risk, but large ones (greater than 15 mm) pose some risk

for cancer, so the gallbladder should be removed. Patients with

polyps 10 mm to 15 mm have a lower risk but they should still discuss

removal of their gallbladder with their physician. Of special note is

a condition called primary sclerosing cholangitis, which causes

inflammation and scarring in the bile duct. It is associated with a

lifetime risk of 7% to 12% for gallbladder cancer. The cause is

unknown, although primary sclerosing cholangitis tends to strike

younger men who have ulcerative colitis. Polyps are often detected in

this condition and have a very high likelihood of malignancy.

Symptoms of gallbladder cancer are usually not present until the

disease has reached an advanced stage and may include weight loss,

anemia, recurrent vomiting, and a lump in the abdomen. When the

cancer is caught at an early stage and has not spread deeper than the

mucosa (the inner lining), removal of the gallbladder results in five-

year survival rates of 68%. If cancer has spread to deeper layers,

more extensive surgery or other treatments may be required.

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* WHAT ARE GALLSTONES AND GALLBLADDER DISEASE?

* WHAT ARE THE SYMPTOMS OF GALLSTONES AND GALLBLADDER DISEASE?

* HOW SERIOUS ARE GALLSTONES AND GALLBLADDER DISEASE?

* WHO GETS GALLSTONES AND GALLBLADDER DISEASE?

* HOW CAN GALLSTONES AND GALLBLADDER DISEASE BE PREVENTED?

* HOW ARE GALLSTONES AND GALLBLADDER DISEASE DIAGNOSED?

* WHAT IS THE GENERAL APPROACH FOR TREATING GALLSTONES AND

GALLBLADDER DISEASE?

* WHAT ARE THE SURGICAL PROCEDURES FOR GALLSTONES AND GALLBLADDER

DISEASE?

* HOW ARE LITHOTRIPSY AND DISSOLUTION THERAPIES USED FOR GALLSTONES?

* HOW ARE COMMON BILE DUCT STONES (CHOLEDOCHOLITHIASIS) MANAGED?

* WHERE ELSE CAN HELP FOR GALLSTONES AND GALLBLADDER DISEASE BE

OBTAINED?

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Review Date: 9/30/2002

Reviewed By: Harvey Simon, MD, Editor-in-Chief, Well-Connected

reports; Associate Professor of Medicine, Harvard Medical School;

Physician, Massachusetts General Hospital. C. Shellito, MD,

Surgery, Harvard Medical School; Associate Visiting Surgeon,

Massachusetts General Hospital

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