What is cholelithiasis?

Cholelithiasis is the presence of stones (gallstones) inside the gallbladder, a small sac-shaped organ located near the liver, measuring between 7 and 10 cm in length. The gallbladder stores bile, which is produced by the liver.

The main function of bile is to digest fats and aid in the absorption of nutrients such as vitamins A, D, E, and K. It is composed of water, cholesterol, bile salts, bilirubinate, and lecithin. When these substances are in balance, bile remains in a liquid state.

When the liver produces excess cholesterol, bile salts, or bilirubinate, these substances precipitate and form small granules. These granules initiate the formation of gallstones. The formation of these stones is more related to metabolic, hereditary, and organic factors than to diet, so food intake does not significantly influence this process. There are two types of stones that may be found in the gallbladder: cholesterol stones and bile salt stones. They may be single or multiple, ranging from tiny grains to large stones.

Risk Factors

The main risk factors include:

chronic hemolytic anemia
significant weight loss: increases cholesterol loss in bile
pregnancy
advanced age
women of childbearing age, especially around 40 years old
women with multiple pregnancies
obesity
patients who have undergone gastric surgery
sedentary lifestyle
use of oral contraceptives
duodenal ulcers
use of parenteral nutrition

Symptoms

Patients are often asymptomatic and may not even be aware of the condition. Sometimes, gallstones are discovered during investigations for other conditions.

The initial symptom is biliary colic, characterized by sharp, continuous pain located in the gallbladder region or above the navel, which may radiate to the right shoulder blade. This pain often occurs after eating fatty foods.

For those who do experience symptoms, the most common include:

intolerance to fatty foods
pain in the upper and central abdomen or upper right quadrant
general discomfort
nausea
vomiting (accompanied by abdominal pain)

Complications

Biliary colic: occurs when a stone gets stuck at the gallbladder’s exit, blocking bile flow and causing significant distension and pain.

Acute cholecystitis: inflammation of the gallbladder due to a stone lodged at the exit for a prolonged period, causing intense, constant pain, usually with fever.

Choledocholithiasis: when a stone migrates from the gallbladder to the common bile duct, blocking it. This duct carries bile from the liver to the intestine, and its obstruction leads to jaundice (yellowing of the skin and eyes), as bile accumulates in the blood and in the liver.

Cholangitis: infection of the bile ducts due to bacterial growth in stagnant bile after obstruction.

Biliary pancreatitis: inflammation of the pancreas caused by a stone blocking the ducts shared by the bile and pancreatic juices, leading to pancreatic self-digestion.

Diagnosis

Abdominal ultrasound is the preferred test for detecting gallstones, with 95% sensitivity and specificity. It can also detect biliary sludge. CT scans, MRI, and oral cholecystography (rarely used today despite its accuracy) are alternatives.

Endoscopic ultrasound is particularly useful for detecting stones smaller than 3 mm and may be necessary when other tests are inconclusive. Laboratory tests generally do not assist in diagnosis.

Treatment

Several factors must be considered when treating gallstones, with the main one being the patient’s symptoms. Symptomatic stones are an indication for surgical treatment.

In asymptomatic cases, all variables must be analyzed to decide whether surgery is necessary.

Laparoscopic surgery has made surgical indications more flexible, as the risk of complications is lower compared to the risks of disease-related complications (cholecystitis, pancreatitis, cholangitis, etc.).

In general, patients with a family history of cancer, hematologic diseases, stones larger than 1 cm, or the presence of both stones and polyps should undergo surgery—whether conventional, laparoscopic, or robotic.

By Einstein Editorial Board