Gallstone disease: prevention, diagnosis and when to see a doctor

Most gallstones show no signs for years and are found incidentally on ultrasound. However, in some people they cause attacks of pain, inflammation of the gallbladder or pancreatitis. The editorial team gathered what is important to know in practice: how to reduce the risk, how the diagnosis is made and which symptoms mean you must see a doctor immediately.

Asymptomatic stones and biliary colic

A significant proportion of people with stones have no complaints. For asymptomatic cholecystolithiasis, EASL guidelines generally do not recommend preventive removal of the gallbladder, except in certain high-risk situations. Each year symptoms appear in only a small proportion of such patients.

The typical symptom is biliary colic: severe constant pain in the right upper abdomen or epigastrium lasting from half an hour to several hours, which may radiate to the right shoulder blade and often occurs in the evening or at night, frequently after a heavy meal. Despite its name, the pain is usually not wave-like.

It is important to distinguish colic from nonspecific symptoms: bloating, belching and heaviness after eating are not by themselves reliable signs of gallstones. That is exactly why removing the gallbladder 'because of bloating' often brings no relief.

For athletes, pain in the right upper abdomen has a wider differential range: from a 'liver stitch' while running and muscle injuries to liver damage from drugs. It is hard to distinguish these conditions on your own, so recurring episodes require examination.

Prevention: what really works

The best-founded prevention is maintaining a healthy body weight without sharp fluctuations. If you need to lose weight, the pace of weight loss should be moderate. Data on bariatric patients show that it is precisely rapid weight loss that is one of the strongest provokers of stone formation.

Regular physical activity is associated with a lower risk of symptomatic disease. A diet with enough fiber, vegetables, legumes, nuts and with a limit on refined carbohydrates has observational support. You should not completely exclude fat: a small amount of it in every meal stimulates contraction of the bladder.

• a moderate pace of weight loss instead of drastic 'cuts';
• a small amount of fat in every meal, regular eating without long hungry intervals;
• enough fiber, vegetables, legumes and whole-grain products;
• regular physical activity;
• discussing with a doctor drugs that increase the risk.

Ursodeoxycholic acid (UDCA) in randomized trials reduced the frequency of stone formation during rapid weight loss after bariatric surgery. EASL allows its use in such situations, but this is a doctor's decision, not a self-prescribed 'liver' supplement.

For those who use prescription drugs that affect the risk (estrogens, GLP-1 agonists, octreotide), prevention consists of discussing the risks with a doctor and responding to symptoms in a timely manner.

Diagnosis: which examinations are needed

The main diagnostic method is transabdominal ultrasound. It is noninvasive, accessible and has high sensitivity for stones in the gallbladder. The examination is performed on an empty stomach so that the bladder is full. Ultrasound also detects signs of inflammation: wall thickening, fluid around the bladder, tenderness when pressing with the probe.

Blood tests help assess complications. A complete blood count shows inflammation, liver function tests (ALT, AST, alkaline phosphatase, GGT, bilirubin) suggest whether the bile duct is blocked, and lipase indicates whether there is pancreatitis. In athletes it is important to remember that intense training can raise AST and ALT due to the muscle component.

If a stone in the common bile duct is suspected, MR cholangiopancreatography or endoscopic ultrasonography is used. Endoscopic retrograde cholangiopancreatography (ERCP) is today used mainly as a therapeutic procedure to remove a stone.

CT is less sensitive specifically to cholesterol stones, but it is useful for complications and for ruling out other causes of pain. The choice of method always depends on the clinical situation, so the optimal path is a consultation with a gastroenterologist or surgeon.

Warning symptoms: when to seek care immediately

There are situations when you cannot wait. Pain in the right upper abdomen lasting more than a few hours, especially with a rise in temperature, indicates possible acute cholecystitis. This is a condition that requires examination by a doctor the same day.

Yellowing of the skin or whites of the eyes, dark urine and light stool indicate impaired bile outflow. If fever and chills are added to this, cholangitis is possible - a dangerous infection of the bile ducts that requires emergency care.

1. pain over 4-6 hours or with fever;
2. jaundice, dark urine, light stool;
3. fever with chills;
4. severe pain in the epigastrium with vomiting.

Severe girdling pain in the upper abdomen with vomiting can mean biliary pancreatitis. This is one of the most common causes of acute pancreatitis overall, and its course can be severe.

An ordinary scheduled visit to a doctor is appropriate if you have had recurrent episodes of characteristic pain, even if they passed on their own. After the first colic the risk of repeated attacks and complications is substantially higher than in asymptomatic people.

Treatment and return to training

For symptomatic stones the standard of treatment is laparoscopic cholecystectomy. Modern guidelines recommend performing it early in acute cholecystitis, within a few days of the onset of symptoms, which shortens the overall duration of the disease.

Dissolving stones with UDCA drugs is possible only for small radiolucent cholesterol stones in a functioning bladder and takes months, and after stopping treatment the stones often return. That is why this method has limited use.

After laparoscopic surgery most people return to ordinary daily activities within a few days. The timing of return to strength training and contact sports is determined by the surgeon, taking into account healing of the abdominal wall punctures and the risk of hernias.

Life without a gallbladder for most people does not require a special diet, although some patients may temporarily have looser stools after fatty food. Training restrictions after full recovery are usually not needed.

Editorial conclusions

Gallstones often exist asymptomatically and do not require treatment, but the appearance of characteristic pain changes the tactics. The basis of diagnosis is ultrasound and blood tests, and the standard of treatment for symptomatic stones is laparoscopic cholecystectomy.

For athletes the most important prevention is to avoid sharp weight fluctuations and extremely low-fat diets, and also to discuss with a doctor any drugs that increase the risk.

Prolonged exhausting 'endurance' of pain in the right upper abdomen is a poor strategy: complications such as cholecystitis, cholangitis and pancreatitis are far more dangerous than scheduled surgery.

We also advise reading our articles on the causes of gallstone disease in athletes, on liver enzyme tests in athletes and on the principles of safe weight loss.

References

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