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Gallstones

Dr Thng Yongxian

Hepatopancreatobiliary & General Surgeon
MBBS • MMed • MRCS (IRE) • FRCSED • FAMS

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What Are Gallstones?

Gallstones are small, hard deposits that form in the gallbladder, a small organ located under the liver. They can vary in size and number, and there are two main types of gallstones: cholesterol stones and pigment stones.

 

In many cases, gallstones do not cause any symptoms and do not require treatment. If a gallstone blocks the flow of bile through the bile ducts, it can lead to inflammation or infection of the gallbladder or other serious conditions affecting the liver and pancreas.

Types of Gallstones

Cholesterol Gallstones

  • Composition: Predominantly made of hardened cholesterol, these stones account for around 80% of all gallstone cases. They also contain other substances found in bile.
  • Appearance: They are usually yellow-green and can vary in size and shape.
  • Formation: These stones form when bile contains too much cholesterol and not enough bile salts.

Pigment Gallstones

  • Composition: Composed mainly of bilirubin, pigment stones are formed from the breakdown products of red blood cells.
  • Appearance: These stones are smaller and darker, typically black or dark brown.
  • Formation: Conditions that cause increased red blood cell destruction, such as sickle cell anaemia, can lead to elevated bilirubin levels in bile, resulting in pigment gallstones.

Causes and Risk Factors

The formation of gallstones is influenced by several factors, including:

Chemical Imbalance in Bile

The primary cause of gallstone formation is an imbalance in the chemical composition of bile, a digestive fluid produced by the liver. This imbalance can lead to the crystallisation of bile components, forming gallstones. For cholesterol stones, the imbalance involves an excess of cholesterol in bile, while for pigment stones, it is an excess of bilirubin.

Gallbladder Function

The gallbladder’s main role is to store and concentrate bile. If the gallbladder does not empty completely or regularly, the resulting concentrated bile may increase the risk of gallstone formation.

Other Risk Factors

  • Gender and Age: Women, especially those over 40 years old, have a higher risk of developing gallstones due to hormonal differences that may affect bile composition.
  • Obesity: Obesity can increase cholesterol in bile and reduce gallbladder movement, leading to gallstone formation.
  • Diet: A diet high in fat and cholesterol and low in fibre can increase the risk of gallstones.
  • Family History: A genetic predisposition to gallstones can be inherited, making family history a significant risk factor.

Symptoms

Many people with gallstones do not experience symptoms. When symptoms do occur, they often include:

  • Biliary Colic: This is the most common symptom, characterised by sudden, severe pain in the upper right or centre abdomen. The pain may last from a few minutes to several hours and can radiate to the back or the right shoulder blade.
  • Nausea and Vomiting: These symptoms often accompany the pain of biliary colic.
  • Jaundice: If a gallstone blocks the bile duct, it can cause bile to build up in the liver, leading to yellowing of the skin and eyes.
  • Bloating

Diagnosis

The diagnosis of gallstones involves a combination of clinical assessment, imaging studies, and sometimes laboratory tests:

Ultrasound

This is the primary imaging technique used to detect gallstones. It is non-invasive and highly effective at identifying stones within the gallbladder.

Computed Tomography Scan (CT Scan)

CT scans can help diagnose complications or rule out other causes of abdominal pain.

Magnetic Resonance Cholangiopancreatography (MRCP)

MRCP is a specialised MRI technique that can visualise the biliary and pancreatic systems, providing valuable insights for diagnosing conditions like gallstones.

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Treatment Options

Non-Surgical Treatments

  • Medications: Medication is ineffective in the treatment of gallstones. Fragmentation of stones can potentially lead to serious complications like cholangitis and pancreatitis.
  • ERCP (Endoscopic Retrograde Cholangiopancreatography): ERCP can remove gallstones from the bile duct. This procedure involves using an endoscope and is particularly useful if stones have passed into the bile duct.

Surgical Treatments

  • Laparoscopic Cholecystectomy: This is a minimally invasive surgical procedure where several small incisions are made in the abdomen to remove the gallbladder using a laparoscope and surgical instruments. The surgeon performs the operation while viewing a video monitor that displays the internal view of the abdomen.
  • Open Cholecystectomy: In an open cholecystectomy, a single, larger incision is made in the abdomen to access and remove the gallbladder. This surgical treatment may be preferred in cases where the gallbladder is severely diseased, making removal more challenging, or when complications arise during a laparoscopic procedure.

Preventative Measures

Preventing the formation of gallstones may not always be possible, but some measures can reduce the risk.

  • Healthy Weight Management: Maintaining a healthy weight can help prevent gallstones, as obesity and rapid weight loss are significant risk factors for their development.
  • Balanced Diet: A diet high in fibre and healthy fats and low in refined carbohydrates and unhealthy fats can help prevent gallstones.
  • Regular Physical Activity: Aim for at least 150 minutes of moderate-intensity aerobic activity, such as brisk walking, or 75 minutes of vigorous-intensity activity, such as running each week.
  • Control of Blood Sugar Levels: For people with diabetes or insulin resistance, controlling blood sugar levels through diet, exercise, and medication can help reduce the risk of gallstones.

Dr Thng Yongxian

Senior Consultant

HEPATOPANCREATOBILIARY & GENERAL SURGEON

MBBS (SG) • MMed (Surg) • MRCS (Ire) • FRCSEd (Gen) • FAMS (Surg)

Dr Thng Yongxian is a dual fellowship-trained Hepatopancreatobiliary & General Surgeon who has performed over 6000 surgical procedures.

  • Bachelor of Medicine & Bachelor of Surgery
  • National University of Singapore
  • Membership of the Royal College of Surgeons, Ireland
  • Master of Medicine, General Surgery, Singapore
  • Fellow of the Royal College of Surgeons, Edinburgh
  • Fellow of the Academy of Medicine, Singapore

He pursued his subspecialty training in Hepatopancreatobiliary surgery first in the Department of Hepatopancreatobiliary Surgery, Singapore General Hospital. Following this, he completed a clinical fellowship in Minimally Invasive Hepatopancreatobiliary Surgery at Seoul National University Hospital in Bundang, South Korea.


Dr Thng set up and pioneered the Minimally invasive surgery program for his hospital in complex liver and pancreas cases. His surgeries were featured on live national television. His surgical videos have also been presented at international surgical conferences. He also pioneered the use of capsule colonoscopy for colorectal screening.


Dr Thng has served on various committees at hospital, cluster and ministry level. Dr Thng served as a member of the Ministry of Health (MOH) Laparoscopic cholecystectomy Clinician workgroup for value-driven care (VDC).

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