GALL STONE DISEASE (GSD)

Gall stones are abnormal solid elements present in the gall bladder. It can come at any age and can manifest at any age of life.

The diagnosis of gall stone related problems is suspected by the clinical symptoms and diagnosed by ultrasonography of the abdomen.

When detected then the treatment depends on the clinical background of the individual patient, presence of gall stone related complications and the associated co morbid conditions.

Age group:

         Gall stone can come at any age. But usually come in the middle age between 30 to 50 years of age. Most of the times stone formation is much earlier than the actual time of clinical presentation. Most important point to be noted is that the gall stone formation is diagnosed when it presents with its complications like jaundice or pancreatitis.

Sex

         Females are much more commonly affected than males. The estimated ratio is about 3:1.

Causes of gall stones:

        There is no one particular reason to say the cause of gall stone formation. But there are some proposed mechanisms for the formation of gall stones like altered concentrations of cholesterol and bilirubin in the gall bladder. Also, dysmotility of the gall bladder and altered hormonal (Oestrogen) changes are other proposed reasons for gall stone formation. But, well documented reason for gall stone formation is persistent gall bladder infection with typhoid bacteria (Salmonella typhi). The possible reasons for gall stone formations are:

1.Too much cholesterol in the bile.

          Any individual having too much cholesterol in the bile can leads to yellow cholesterol stone formation. These hard stones may develop if the liver makes more cholesterol than normal. So, the amount of bile salts presents at a given time is not sufficient to dissolve the cholesterol present in the bile.  Cholesterol stones are yellow in colour. Pure cholesterol stones are rare. More common Is mixed stone in which there will be combination of cholesterol and pigments and the colour will be yellow to brown or brown black.

2.Too much bilirubin in the bile

           Bilirubin is a pigment produced when haemoglobin and myoglobin are destroyed. Some conditions like chronic liver damage and certain blood disorders like haemolytic anaemia causes more bilirubin in the blood which leads to more bilirubin in the bile.  So, individuals with excess bilirubin in the bile will leads to pigment gallstone formation. The bile pigment stones can be black (pure) or brown (also containing cholesterol). Black bile pigment stones are hard and brittle while often dark brown stones are soft and crumbly.

3.Improper emptying of the gall bladder.

       When the gall bladder is not able to empty the bile adequately by some reasons then there will be stagnation of bile in the gall bladder. This condition is more common with females with hormonal imbalance. The alterations of oestrogen and progesterone have a role in the development of gall stone formation. The gallbladder has to empty its bile in to the duodenum periodically so that the gall bladder will be healthy. If it fails to empty its bile content, then the bile becomes more concentrated, which causes stone formation. One important example is following surgery for duodenal ulcer. The surgical management of complicated duodenal ulcer involves the division of both vagus nerves which may end up with gall bladder dysfunction and gall stone formation.

4.Oestrogen and gall stones.

          Too much oestrogen (oestrogen dominance), for example, can trigger the liver to produce too much cholesterol relative to bile salts and lecithin in bile, increasing saturation of bile with cholesterol, which leads to cholesterol crystal formation. Oestrogen also alerts bile acid composition, increasing the chance of gall stone formation

5.Chronic infection

          Presence of chronic infection in the gall bladder is the one of the important reasons for gall stone formation. The most important one is chronic infection of gall bladder with typhoid bacteria (Salmonella typhi) infection.

Salmonella typhi infection and Gall stone formation.

   Typhoid or enteric fever is caused primarily by Salmonella enterica subsp. enterica serovar Typhi and is a human-specific disease.  Typhoid is an acute illness often characterized by high fever, malaise and abdominal pain. Globally, children are disproportionately affected, especially in south central Asia and Southeast Asia. Serious complications include intestinal perforation, septicaemia and meningitis, with the highest incidence of these being found in paediatric and immunocompromised patients. These complications are life threatening and require advanced medical care.

     Typhoid is most commonly spread by ingestion of contaminated water or food. Following entry into the small intestine, the bacteria cross the intestinal epithelial barrier (probably by invasion of microfold (M) cells in the Peyer’s patches and lymphoid-associated tissues), are phagocytosed by macrophages and spread systemically, producing acute disease. The most common sites of infection are the ileum, liver, spleen, bone marrow and gall bladder.

       The bacteria reaches the gall bladder through the vasculature or the ducts that emanate from the liver. Fortunately, with adequate treatment, most patients recover from the acute phase of typhoid; however, 3–5% of individuals who are infected with S. Typhi develop a chronic infection in the gall bladder. Because S. Typhi is a human-restricted pathogen, these chronic carriers form a crucial reservoir for the further spread of the disease through bacterial shedding in faeces and urine. Chronic S. Typhi infections can persist for decades, and although infected individuals are highly contagious, they are typically asymptomatic, making the identification of carriers difficult. The situation is further complicated by the fact that approximately 25% of carriers experience no clinical manifestations during the acute phase of the disease.

    Epidemiological studies conducted in endemic regions have indicated that there is a strong link between the development of the chronic carrier state and the presence of gallstones; in fact, approximately 90% of chronically infected carriers have gallstones.

6.Genetic Factors:

          The gall stone disease is noticed in patients from same family like mother and daughter, among sisters, among siblings and father and son. The gall stones are noted in three generation of patients also. This is the evidence to say that the gall stone disease may be genetically related.

   General Risk factors for gall stone formation

      Possible Factors which may increase the risk of gallstones formation include:

• Being female
• Being overweight or obese
• Being sedentary
• Being pregnant
• Eating a high-fat diet
• Eating a high-cholesterol diet
• Eating a low-fibre diet
• Having a family history of gallstones
• Having diabetes
• Losing weight very quickly
• Taking medications that contain oestrogen, such as oral contraceptives or hormone therapy drugs
• Having liver disease