By Katie E. Golden, MD
Gallstones are a common condition we diagnose in the emergency department (ED), and can sometimes lead to repeated visits for recurrent episodes. If you have been diagnosed with gallstones, here are some important things to understand about these pesky little pebbles that are often more trouble than our gallbladder is worth.
First, what are gallstones?
Gallstones come from the gallbladder, which is a small sac-like organ that sits underneath the liver and is part of our digestive system. It stores bile and enzymes and releases them into the intestine when we eat to promote digestion in the small intestine (see image below). Sometimes, these gallbladder juices can change consistency and develop ‘stones’ or ‘sludge’, like the way soft mud can turn into clay or rocks. This process is not necessarily problematic by itself but can lead to some problems for the patient . . .
Why do gallstones cause pain?
Gallstones are a common finding, and often do not cause any pain or problems when they remain peacefully in the gallbladder. As the gallbladder is squeezing its gallbladder juice into the intestine, however, one of these stones can decide to go on a little field trip into the small intestine along with the surrounding bile. When this happens, the stones can get lodged in the narrow part of the gallbladder (called ‘the neck’), or the smaller duct that connects the gallbladder to the intestine (called ‘the common bile duct’). This leads to painful episodes as the stone travels through a narrow passage, like Santa Clause getting shoved down a chimney after a night full of cookies and milk.
An episode of ‘biliary colic’, as we refer to it, is most likely to develop after eating when the gallbladder is actively contracting. It often feels like sharp or band-like pain in the upper abdomen (typically worse on the right side, where the gallbladder is located), but can sometimes feel more like pain in the chest, back, or even the right shoulder. It is common to also experience nausea and vomiting along with the pain. Most times, the pain eventually resolves when the gallbladder calms down or the stones passes into the intestine, however, the length of an episode can be highly variable.
What is the treatment for gallstones?
The only way to prevent future episodes of biliary colic is to surgically remove the gallbladder (it is a non-vital organ and patients can still have normal and healthy digestion without it). A visit to the ED for gallstones usually entails treating the patient’s pain, and then providing a referral to a general surgeon to arrange an elective procedure to remove the gallbladder (if the patient chooses to pursue that option).
Surgery is an easy choice for most patients who experience frequent episodes of pain that is significantly impacting their quality of life. Some patients, however, have much milder or infrequent symptoms and they simply rely on dietary changes and pain medication to manage these episodes. Typically this requires having pain and nausea medication on hand when an episode of biliary colic occurs and does not quickly resolve. Additionally, as bile secretion is typically triggered by foods higher in fat and cholesterol, a low-fat diet may help to control symptoms.
What are the potential complications of gallstones?
The main goal of an ED visit for gallstones is to primarily relieve the patient’s pain. During that visit, we will also evaluate for signs of complications that would require emergency removal of the gallbladder or culprit stone.
One of the most common reasons a gallbladder needs to be removed on an urgent basis is for ‘cholecystitis’, which is an infection of the gallbladder. When gallstones are lodged in the gallbladder or duct for a prolonged period of time, this can sometimes lead to inflammation and infection of the gallbladder itself. In these cases, the patient is started on antibiotics and typically requires surgery within 24 to 48 hours. There are other, more rare cases when the gallstone is lodged in a particular location such that is causes an infection of the bile duct, or even the pancreas (which also lives nearby). These conditions are often treated with procedures that endoscopically remove the gallstone, rather than the gallbladder.
When do I know if I need to return to the emergency department for my gallstones?
Unfortunately, gallstones can lead to multiple ER visits for repeated episodes of pain. While most patients do well with pain medication and outpatient follow-up, some episodes of pain can be severe and unrelieved at home. If a patient is in pain, and medication (and time) is not doing the trick, they should return so we can help alleviate their symptoms and rule out infection.
Given the potential complications listed above, it is also important that someone with gallstones return for certain symptoms, which are indicative of a developing infection that would require a procedure or surgery:
- Persistent or increasing pain, especially if the patient does not get any relief over several hours
- Accompanying fevers or chills
- While the patient will often get nauseated and sometimes vomit with the pain, repeated or uncontrollable vomiting is atypical and requires evaluation
- Jaundice (a yellow discoloration of the eyes or skin)
- Confusion or altered level of mentation, often seen in older patients with infection