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Gallstones and Bile Duct Stones in the Elderly

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Gallstones are hard deposits that develop in the gallbladder due to accumulation of bile components. It can affect any age group and up to 60% of cases seen in the United States is in people over the age of 60 years. Gallstones can remain in gall bladder in which case it is known medically as cholelithiasis or can be impacted in the common bile duct when it is then referred to as choledocholithiasis. It may be silent (no symptoms) or may present with sudden onset upper abdominal pain often associated with nausea and vomiting. Gall stones in the common bile duct may lead to two serious complications pancreatitis and ascending cholangitis. Treatment in the form of surgery is recommended only in symptomatic cases and the entire gallbladder is often removed.

Gallstones Symptoms

Gallstones may be asymptomatic. Symptoms arise if the gallstones become impacted in the gallbladder, block the outlet from gall bladder (cystic duct), or become lodged in the common bile duct. Symptoms of impacted gallstones in the gallbladder include :

  • Sudden onset intense pain on right upper abdomen spreading towards center of the abdomen and right shoulder.
  • Nausea and vomiting.
  • Typically night pain and following heavy meals.

Gallstones present in the gallbladder may erode the walls of the gallbladder and adjoining bowel causing obstruction of intestine (gallstone ileus) characterized by :

  • Abdominal distension
  • Constipation with complete absence of passage of bowel gas.
  • Nausea and vomiting.

Symptoms of a blocked common bile duct by gallstone may lead to :

  • Jaundice – yellowish discoloration of skin and mucous membrane due to obstructed bile flow.
  • Liver damage characterized by blood clotting disorder and raised liver enzymes.
  • Impacted gallstones in the common bile duct may lead to two life threatening conditions.

Pancreatitis, due to abnormal activation of digestive enzymes in the pancreas causing autodigestion of pancreatic tissue, presents with abdominal pain, nausea, vomiting, fever, jaundice and weight loss. Pancreatitis may lead to pancreatic cancer and diabetes.

Ascending cholangitis is an infection ascending from the first part of the small bowel to the site of impacted stone at the common bile duct. It is characterized by abdominal pain, fever with chill and rigor, jaundice, body ache, mental confusion and low blood pressure due to septic shock.

Causes of Gallstones

Bile contains cholesterol and bile salts which enhance the solubility of cholesterol. When these components precipitate in the gallbladder it forms biliary sludge which can then develop into gallstones. The interplay of following factors usually leads to gallstones :

  • High cholesterol: diet, lipid disorder, drug induced (oral conrtraceptive pills).
  • Low bile salts.
  • Poor gallbladder mobility causing stagnation of bile and increased chance of infection by bacteria.
  • Increased destruction of blood cells (hemolytic anemia) and abnormal production of hemoglobin (porphyria).

Types of Gallstones

Gallstones are of the following types :

  • Cholesterol stones contain more than 80% of holesterol.
  • Pigment stone contain less than 20% cholesterol and the major constituent is pigments and bilirubin.
  • Mixed stones.

Risk Factors

Common risk factors include :

  • Being female.
  • Age over 40 years.
  • Obesity.
  • Pregnancy.
  • High fat (cholesterol) and low fiber diet.
  • Family history.
  • Diabetes mellitus.
  • Certain drug intake (oral contraceptive pills, hormone replacement therapy).
  • Associated hemolytic anemia (increased breakdown of blood cells).

Treatment of Gallstones

No treatment is required in the case of asymptomatic gallstone. Treatment options include :

  • Surgery: open or laparoscopic to remove gallstones usually with the gallbladder removed as well.
  • Drugs to dissolve gall stones are unreliable and can take months to years. It is used only in patients where surgery cannot be done.

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