Gallstones
The gallbladder is attached to the liver and stores bile, which aids in the digestion of fat in the
small intestine. The cystic duct attaches the gallbladder to the bile duct, and the bile duct carries
bile from the liver to the small intestine. In some people, the bile becomes thick and gallstones
form in the gallbladder. Gallstones consist of crystallized cholesterol or calcium crystals ionized
with bilirubin. Cholesterol stones are more common. The stones impede bile flow.
While many people have gallstones, it is estimated that only 1% to 4% of these patients will have
symptoms, and that only 5% of symptomatic patients will develop pancreatitis. Symptoms of
gallstones include pain, indigestion, feeling full, and discomfort in the right upper part of the
abdomen. These symptoms usually occur after eating a fatty meal.
Complications of gallstones
Acute cholecystitis: A stone blocks the cystic duct, and the gallbladder is unable to empty bile,
which accumulates and becomes infected. The gallbladder is inflamed.
Cholangitis: Cholangitis results from acute infection concurrent with obstruction of the biliary
tree. Patients with cholangitis who do not respond to conventional therapy and do not have
appropriate drainage have mortality rates near 100%.
Jaundice: Jaundice develops when a stone blocks the bile duct. Patients have yellowish
discoloration of the skin and eyes, along with severe itchiness.
Gallstone pancreatitis: If the pancreatic duct is blocked by a stone at the sphincter of Oddi,
outflow of all material from the liver and pancreas results. Many patients have gallstones in their
feces, suggesting that bile refluxes into the pancreas. It also is suggested that a compromised
sphincter of Oddi leads to reflux of the duodenal contents into the pancreatic duct. Furthermore,
gallstones can block the flow of digestive enzymes from the pancreas, which results in
inflammation of the pancreas.
Gallbladder cancer: Patients who have gallstones for more than 15 years have a higher risk of
developing cancer.
Risk factors for gallbladder disease
Risk factors for gallbladder disease are described for decades as the “five Fs,” meaning fair
skinned, fat, female, fertile, and 40 years of age or older. Other risk factors include high
cholesterol levels, use of medications that contain estrogen, rapid weight loss, diabetes, and
pregnancy. Certain populations, such as Latinos and Pima Indians, are at higher risk for
gallstones.
Individuals with disorders that cause destruction of red blood cells, such as sickle-cell anemia,
are much more likely to develop pigment stones. Patients undergoing gastric bypass surgery are
at a high risk for developing gallstones; some research has suggested that bile salt therapy
(ursodeoxycholic acid) or prostaglandin inhibition (ibuprofen) may prevent gallstone formation
in this high-risk group, but other research has shown that these measures are unsuccessful
Endoscopic retrograde cholangiopancreatography
Endoscopic retrograde cholangiopancreatography (ERCP) is used for individuals with
progressive biliary obstruction. For patients without biliary obstruction, research has found that
the procedure is not helpful and is sometimes damaging; the most common complication is
severe pancreatitis. ERCP involves the passage of a thin, flexible scope into the duodenum,
where it is used to assess the common bile duct or pancreatic duct. It is possible to remove stones
during the procedure. The ERCP with sphincterotomy and drainage of the bile duct with
extraction of the gallstones are used in cases of cholangitis, although in some cases surgeons
choose to do a percutaneous transhepatic cholangiography instead.
Cholecystectomy
More than 50,000 cholecystectomies are performed each year in America, but some physicians
avoid excision of the gallbladder unless the patient has symptoms. Because patients with diabetes
often do not sense pain, they are more likely to undergo a cholecystectomy. Laparascopic
cholecystectomy remains the gold standard for patients with stones in the gallbladder itself; this
prevents recurrent pancreatitis while allowing the surgeon to assess the bile duct. For patients
who are too high risk to undergo surgery, the medication ursodiol is sometimes used to dissolve
cholesterol gallstones, although it can take months before it is effective and recurrence of the
stones after treatment completion is common.
Food allergies
Some experts contend that undiagnosed food allergies cause swelling of the bile duct and
subsequent compromised bile flow.
Reports of potentially problematic foods include:
 Beans
 Coffee
 Corn
 Eggs
 Milk
 Nuts
 Onions
 Oranges
 Pork
 Poultry
It seems that identification and avoidance of allergenic foods frequently relieve symptoms of
gallbladder disease, although it does not dissolve gallstones.
Vitamin C
Vitamin C may help the body to digest dietary fat and lower the risk of gallstones. Some animal
research has found that vitamin C and vitamin E deficiency increase the risk of gallstones, as has
insufficient levels of lecithin. Iron deficiency seems to alter hepatic enzyme metabolism and
promote cholesterol crystal formation in women. Other supplements that may help include
choline, methionine, folic acid, and vitamin B12. Milk thistle might help to improve the liquidity
of bile, and peppermint oil might help to dissolve gallstones. Psyllium binds to cholesterol in bile
and prevents gallstone formation and constipation.
How to reduce the risk of gallstone formation
It is possible to reduce the risk of gallstone formation by adopting a diet that is high-fiber, lowfat (you want to consume a small amount of fat at each meal, because fat causes the gallbladder
to empty), and low-sugar (sugar and consumption of a high-carbohydrate diet appears to increase
risk), and by maintaining adequate hydration and a healthy body weight. Consumption of nuts,
fruits, vegetables, and monounsaturated fats is hypothesized to decrease risk. Not skipping meals
helps prevent gallstones.
Losing weight and then regaining it also seems to increase the risk of stone formation, as does
losing weight quickly, so a slow and steady pace is recommended. Exercise, regular bowel
movements, and plenty of omega-3 fatty acids and calcium also are recommended.
Some research shows that a moderate amount of alcohol may help to prevent gallstones, but
people who do not currently drink should not start drinking for this reason.
Daily consumption of coffee also may help. It is believed that the caffeine stimulates contraction
of the gallbladder and decreases the concentration of cholesterol in bile. Interestingly, other
caffeinated beverages do not seem to have the same benefit.
References and recommended readings
Center for Pancreatic and Biliary Diseases. Gallstones. University of Southern California, Dept
of Surgery Web site.
http://www.surgery.usc.edu/divisions/tumor/pancreasdiseases/web%20pages/BILIARY%20SYS
TEM/LAP%20CHOLE-GALLSTONES.html. Accessed August 18, 2013.
Choi Y, Silverman WB. Biliary tract disorders, gallbladder disorders, and gallstone pancreatitis.
American College of Gastroenterology Web site. http://patients.gi.org/topics/biliary-tractdisorders-gallbladder-disorders-and-gallstone-pancreatitis/. Updated July 2013. Accessed August
18, 2013.
Gaby AR. Nutritional approaches to prevention and treatment of gallstones. Altern Med Rev.
2009;14(3):258-267.
Gallstone pancreatitis. EndoNurse® Web site.
http://www.endonurse.com/articles/2002/12/gallstone-pancreatitis.aspx. Accessed August 18,
2013.
Gallstones. New York Times Health Guide Web site.
http://health.nytimes.com/health/guides/disease/gallstones/prevention.html. Accessed August 18,
2013.
Gallstones. NYU Langone Medical Center Web site.
http://www.med.nyu.edu/content?ChunkIID=21520. Accessed August 18, 2013.
Gallstones and gallbladder disease. University of Maryland Medical Center Web site.
http://www.umm.edu/patiented/articles/how_can_gallstones_gallbladder_disease_be_prevented_
000010_5.htm. Accessed August 18, 2013.
Gallstones—prevention. WebMD® Web site. http://www.webmd.com/digestivedisorders/tc/gallstones-prevention. Updated July 15, 2011. Accessed August 18, 2013.
Hofmann AF. Primary and secondary prevention of gallstone disease: implications for patient
management and research priorities. Am J Surg. 1993;165(4):541-548.
Johnston SM, Murray KP, Martin SA, et al. Iron deficiency enhances cholesterol gallstone
formation. Surgery. 1997;122(2):354-362.
Mayo Clinic staff. Gallstones. Mayo Clinic Web site.
http://www.mayoclinic.com/health/gallstones/DS00165/DSECTION=alternative-medicine.
Accessed August 18, 2013.
Vitale GC. Early management of acute gallstone pancreatitis. Ann Surg. 2007;245(1):18-19.
doi:10.1097/01.sla.0000250967.32581.c9.
Wudel LJ Jr, Wright JK, Debelak JP, Allos TM, Shyr Y, Chapman WC. Prevention of gallstone
formation in morbidly obese patients undergoing rapid weight loss: results of a randomized
controlled pilot study. J Surg Res. 2002;102(1):50-56.
Contributed by Elaine Koontz, RD, LD/N
Review Date 8/13
G-1879