Gallstones, the Hardened Deposits of Digestive Fluid - Essay Example

Gallstones By Gallstones The presence of gallstones is one of the most common causes of death in the western industrial nations. This disease has a high rate of prevalence in Europe and the United States and low rate of prevalence in Third World countries and in Asia (Adler 2004 p. 3). In the United States, 16 to 22 million people were discovered to have been afflicted with gallstones between the years 1976-87 (Prevalence and Incidences of Gallstones 2008). Also known as cholecystolithiasis, it is the cause for about 200 days of hospitalization per 10000 insured persons in Germany and had cost the German health-care system more than 1.08 billion DM in 1990 alone. Likewise, in the USA, it is one of the most costly gastrointestinal diseases (Adler 2004 p 3). The presence of gallstones is the most common digestive problem associated with the gallbladder (Lipski 2004 p 221). The gallbladder is part of the hepatobiliary system along with the left and right hepatic ducts, the cystic duct and the common bile duct which is formed by the union of the common hepatic duct and the cystic duct. The common bile duct goes down to the duodenum or large intestine to come in contact with the main pancreatic duct, to form the hepatopancreatic ampulla (Porth 2005 p 941-942). There is a close association between the gallbladder and the duodenum that in a cadaver, the duodenum is usually stained with bile (Moore & Dalley & Agur 2006 p 302). The gallbladder is a stretchable, pear-shaped, muscular sac located in the lower part of the liver and has three layers: the outermost layer which is serous and peritoneal; the middle layer which is smooth-muscled, and; the innermost mucosal layer that is continuous with the linings of the bile duct (Porth 2005 p 941-942). The main purpose of the gallbladder is that it stores bile, up to 50 ml at once (Moore & Dalley & Agur 2006 p 302). Bile, which is manufactured in the liver, is made up of bilirubin, bile salts, bile pigments, cholesterol, fatty acids, plasma electrolytes, and water. Of these components, the bile acids, which are transformed to bile salts, are the most important because they perform the following: “emulsify fat globules to aid digestion; join with lipids to form micelles for transport to the intestinal villi for absorption by the lymphatics; activate lipases in the intestine; and stimulate reesterification of fatty acids and glycerol synthesis from glucose. Bile salts are required for absorption of fat-soluble vitamins A, D, E and K (Johnson & Gross 1998 p382). Aside from emulsifying fat like a detergent, bile also helps in fat absorption in the small intestine (Cohen & Taylor 2005 p 394). After bile is manufactured in the liver, bile leaves the area through the two ducts that eventually merge to form the common hepatic duct. This process of passage also includes collecting whatever is bile stored in the gallbladder, the same duct now called at this stage as common bile duct, brings the bile to the duodenum. The manufacture of bile in the liver is a continuous process although the need for bile may only be for several times in the day. Thus, while there is still no need for it, bile is temporarily stored in the gallbladder (Cohen & Taylor 2005 p 394). When food enters the intestine, the gallbladder contracts and the sphincter (the end) of the bile duct relaxes to enable the movement of bile from the gallbladder to the duodenum. The products of digestion especially lipids, stimulates the secretion of a hormone in the duodenum called cholecystokenin which stimulates the gallbladder to contract. When the gallbladder stores bile, its muscles eases up and the pressure in the common duct decreases but when the gallbladder empties bile to the intestine, it contracts and the pressure in the common duct likewise increases, forcing the sphincter dilate (Porth 2005 p 942). Fig. 1 The Gallbladder Gallstones are crystalline structures, made of cholesterol, which can cause blockade in the tubes lying between the gallbladder, liver and the small intestine. As previously stated bile has many components, among of which are cholesterol and biluribin. Gallstone is formed when either of the two or both hardens. It is estimated that 80% of the gallstones are cholesterol precipitates while 20% are black or brown pigment stones composed of calcium salts with biluribin. The cholesterol component of bile has no known function but is believed to have been formed as a byproduct of bile salt formation. It is linked to the excretory function of bile. Cholesterol is not soluble by water but only by its action with bile salt and lecithin, all three of which form micelles. When bile reaches or is stored in the gallbladder, water and electrolytes are absorbed resulting in more concentrated bile. The concentration of bile salts and lecithin correspondingly increases and in this way the solubility of cholesterol is maintained (Porth 2005 p 942). According to the book Pathophysiology, there are three causes of gallstone formation: abnormalities in the composition of bile; stasis of bile, and; inflammation of the gallbladder. There are three kinds of gallstones: mixed stones which contain a mixture of the green pigment in bile and cholesterol which can develop of up to 12 at a time to fit the gallbladder; cholesterol stones are formed from cholesterol and occur singly or in twos and can grow as much as ½ inch in diameter which can block the entire common bile duct, and; pigment stones which are made of green bile pigment which form usually as a result of blood diseases and can occur in small or large numbers (Jacoby & Youngson 2006 p 668). The presence of gallstones is usually asymptomatic. Symptoms are only manifested when they actually obstruct bile flow and that is when acute pain can be felt. When small stones pass into the common duct they produce symptoms of indigestion and biliary colic but large stones can actually obstruct flow and cause jaundice. The symptom of biliary colic is usually an abrupt pain which increases in intensity that goes on for 30 or 60 minutes at the height of its most intense and can be felt in the upper right quadrant, or epigastric area accompanied usually by a “referred pain to the back, above the waist, the right shoulder, and the right scapula or the midscapular region” Some experience pain on the left side which persists for 2 to 8 hours (Porth 2005 p 943). An effect of the presence of gallstones is the inflammation of the gallbladder, a condition called cholecystitis. This condition is due to partial or complete digestion. The concentrated bile which is unable to escape due to obstruction irritates the linings of the gallbladder as well as mucosal swelling and ischemia “resulting from venous congestion and lymphatic stasis.” This bloats the gallbladder and also cause bacterial infection brought through blood, lymphatics, bile ducts or from nearby organs to the gallbladder (Porth 2005 p 943). Gallbladder can be diagnosed through ultrasonography, which has replaced oral cholecystogram, and nuclear scanning (or cholescintigraphy). It can detect stones, as well as gallbladder inflammation, as small as 1 to 2 cm and its accuracy is high. Ultrasonography can rule out tumor as the source of pain in the upper right quadrant pains. On the other hand, scanning is done by injecting radionuclide, technetium-99m which the liver can absorb and empties into the bile ducts. The chemical then acts as a tracer for serial scanning of images. It is highly accurate in detecting inflammation of the gallbladder (Porth 2005 p 943). Gallstones can be treated by disruption or dissolution or in chronic cases, the entire gallbladder is removed. In the first solution, chemical agents may be used to dissolve the stones or they can be removed physically through endoscopic sphincterotomy and extra-corporeal shock wave lithotripsy (ESWL). However, since the invention of the cholecystomy laparoscopic, a surgical procedure in which the entire gallbladder is removed, this surgical option has become the most preferred treatment of gallstones (Warrell et al 2005 p. 703). According to the book Digestive Wellness, one in every five Americans over the age of 65 is a candidate for gallstones with women two to four times more prone to it than men. Diet is a very vital factor in the prevention of gallstones which means that a low-fat, low-meat and vegetarian diets are to be favored in addition to a low-sugar and high fiber intake. Studies have showed that there was an increase risk of gallstones for heavy coffee drinkers. Also obesity makes one prone to the disease (Lipski p 224). References Adler, G. (2004). Gallstones: Pathogenesis and Treatment. Springer. Cohen, Barbara Janson & Taylor, Jason J. (2005). Memmlers The Human Body in Health and Disease. Lippincott Williams & Wilkins. Jacoby, David, & Youngson, B. R. M. Encyclopedia of Family Health. Marshall Cavendish Johnson, Bonny Libbey & Gross, Jody. (1998). Handbook of Oncology Nursing. Jones & Bartlett Publishers. Lipski, Elizabeth. (2004). Digestive Wellness. McGraw-Hill Professional. Moore, Keith L. & Dalley, Arthur F. (2006). Clinically Oriented Anatomy. Lippincott Williams & Wilkins, 2006 Prevalence and Incidence of Gallstones http://www.wrongdiagnosis.com/g/gallstones/prevalence.htm#prevalence_intro Porth, Carol. 92005). Pathophysiology: Concepts of Altered Health States. Lippincott Williams & Wilkins, 2005 Warrell, David A. & Cox, Timothy M. & Firth, John D. & Benz, Edward J. & Weatherall, David. (2005). Oxford Textbook of Medicine: 3-Volume Set. Oxford University Press, 2005 Read More