What about a stomach ulcer, which can lead to serious complications if missed? Given that gallstones are often present but asymptomatic, gallstone disease could often be an erroneous diagnosis once gallstones are identified on an imaging test.

And how about individuals who do not fit into this profile, such as women of color? Might the presence of gallbladder disease in this group be missed? And what about the actual validity of this mnemonic? Does it accurately represent the risk factors and physiology of gallstone disease?

They found that gallstones were more common in women in general, but that men were more likely to have gallstones at older ages.

They found that while women under 50 with children were more likely to have gallstones than those without children, the opposite was true after age Similarly, they found that women under 50 with gallstones had higher weights than those without gallstones, but this was not the case after age A more recent study in looking at the validity of this mnemonic found that family history, which is not included in this mnemonic, is actually one of the strongest risk factors for gallstones.

Despite the inaccuracies of this mnemonic in these studies done over 60 years ago and in the recent past, medical students have continued to learn this biased list. Though the term fat has been reclaimed as an objective descriptor of body size, the term fat in this gallstone mnemonic was used in a stigmatizing way.

It was posited that women who are fat are predisposed to gallstones due to their eating behaviors and cholesterol levels, which could cause gallstones to form. For instance, weight cycling yo-yo dieting increases the risk of gallstones. Studies in both women and men have found that weight cycling as little as lbs has been found to be independently associated with gallstone disease after controlling for BMI, age, fat intake, and alcohol intake.

Rapid weight loss due to very low calorie diets or gastric bypass surgery has also been shown to lead to formation of gallstones. Therefore, it is likely not the body size that is causing the gallstones, but it may instead be the restrictive and repeated dieting that is causing gallstone disease.

Weight bias is pervasive among healthcare providers. Despite our sense of pride in having objectivity in medicine, we as providers carry significant implicit bias and are not neutral in the care that we provide.

Weight stigma that is internalized by individuals can lead to avoidance of care, non-adherence to treatment, and an increase in the risk of a multitude of health conditions. It labels individuals as being to blame for a condition when, in fact, the treatments that we are prescribing to those in larger bodies, including diets and weight loss surgery, may actually be causes of these conditions.

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Harvard researchers have discovered one more reason to watch our waistlines: avoiding gallstone surgery. Their study, published in the journal Gut Feb. The research suggests that waist measurement may be a better predictor of gallbladder risk than body mass index BMI.

Gallstones often produce no symptoms and require no treatment. But they can cause severe pain, jaundice, and inflammation of the gallbladder, bile duct, and pancreas. As a result, , cholecystectomies are performed each year in the United States.

Compared to men, women are twice as likely to have gallstones, and the risk increases with age. The Gut study analyzed 14 years of data from 42, participants in the Nurses' Health Study.

At the outset, none had gallbladder disease; by the end of the study period, the group had undergone 3, gallbladder surgeries. To continue reading this article, you must log in. Subscribe to Harvard Health Online for immediate access to health news and information from Harvard Medical School.

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Gallbladder Polyps Polyps benign growths are sometimes detected during diagnostic tests for gallbladder disease. Primary Sclerosing Cholangitis Primary sclerosing cholangitis is a rare disease that causes inflammation and scarring in the bile duct.

Porcelain Gallbladders Gallbladders are referred to as porcelain when their walls have become so calcified covered in calcium deposits that they look like porcelain on an x-ray. Risk Factors More than 20 million Americans have gallstones, and approximately 1 million are diagnosed each year.

Risk Factors in Women Women at all ages are much more likely than men to develop gallstones. Pregnancy Pregnancy increases the risk for gallstones, and pregnant women with stones are more likely to develop symptoms than women who are not pregnant.

Hormone Replacement Therapy Several large studies have shown that the use of hormone replacement therapy HRT doubles or triples the risk for gallstones, hospitalization for gallbladder disease, or gallbladder surgery.

Risks in Children Gallstone disease is relatively rare in children. The following conditions may put children at higher risk: Spinal injury History of abdominal surgery Sickle-cell anemia Impaired immune system Receiving nutrition through a vein intravenous Ethnicity The risk of gallstone and gallbladder disease in the United States is highest in certain tribes of Native Americans, it is higher in Hispanic Americans than in whites, and lowest in black Americans.

Genetics Having a family member or close relative with gallstones may increase the risk. Diet Cholesterol gallstones are more prevalent in people who consume Western diets of high amounts of saturated fats and cholesterol, protein, and refined sugars, and low amounts of fiber as well as a high total calorie count.

Diabetes People with diabetes are at higher risk for gallstones and have a higher-than-average risk for acalculous gallbladder disease without stones. Obesity and Weight Changes Obesity Being overweight is a significant risk factor for gallstones.

Weight Cycling Rapid weight loss or cycling dieting and then putting weight back on further increases cholesterol production in the liver and an increased risk for gallstones.

a week Those on very low-fat, low-calorie diets Men are also at increased risk of developing gallstones when their weight fluctuates. Bariatric Surgery Patients who have either Roux-en-Y or laparoscopic banding bariatric surgery are at increased risk for gallstones.

Metabolic Syndrome Metabolic syndrome is a cluster of conditions that includes obesity especially belly fat , low HDL good cholesterol, high triglycerides, high blood pressure, and high blood sugar.

Low HDL Cholesterol, High Triglycerides and Their Treatment Although gallstones are formed from the supersaturation of cholesterol in the bile, high total cholesterol levels themselves are not necessarily associated with gallstones. Other Risk Factors Prolonged Intravenous Feeding Prolonged intravenous feeding reduces the flow of bile and increases the risk for gallstones.

Crohn Disease Crohn disease, an inflammatory bowel disorder, leads to poor reabsorption of bile salts from the digestive tract and substantially increases the risk for gallbladder disease. Cirrhosis Cirrhosis poses a major risk for gallstones, particularly pigment gallstones.

Organ Transplantation Bone marrow or solid organ transplantation increases the risk of gallstones. Medications The following drugs may increase the risk for gallstones: The somatostatin analog octreotide Sandostatin.

Fibrates, a type of lipid-lowering agents. Estrogen, whether administered as an oral contraceptive to premenopausal women or as hormone replacement therapy to postmenopausal women. Thiazide diuretics.

The antibiotic ceftriaxone. Blood Disorders Chronic hemolytic anemia, including sickle cell anemia, increases the risk for pigment gallstones. Spinal Cord Injury People with spinal cord injury have a higher prevalence of gallstones and a higher rate of complications from gallstone disease.

Heme High consumption of heme iron, the type of iron found in meat and seafood, has been shown to lead to gallstone formation in men. Prevention Diet may play a role in gallstones. Specific dietary factors may include: Fats.

Although fats particularly saturated fats found in meats, butter, and other animal products have been associated with gallstone attacks, some studies have found a lower risk for gallstones in people who consume foods containing monounsaturated fats found in olive and canola oils or omega-3 fatty acids found in canola, flaxseed, and fish oil.

Fish oil may be particularly beneficial in patients with high triglyceride levels, because it improves the emptying actions of the gallbladder.

High intake of fiber has been associated with a lower risk for gallstones. Studies suggest that people may be able to reduce their risk of developing gallstones by eating more nuts peanuts and tree nuts, such as walnuts and almonds. Fruits and Vegetables.

People who eat a lot of fruits and vegetables may have a lower risk of developing symptomatic gallstones that require gallbladder removal. Vitamin C. In women, higher levels of vitamin C have been statistically associated with a lower prevalence of clinical gallbladder disease.

There is no evidence that taking extra vitamin C prevents or treats gallstones. High intake of sugar has been associated with an increased risk for gallstones. Diets that are high in carbohydrates such as pasta and bread can also increase risk, because carbohydrates are converted to sugar in the body.

Research suggests that drinking coffee every day can lower the risk of gallstones. The caffeine in coffee is thought to stimulate gallbladder contractions and lower the cholesterol concentrations in bile.

However, drinking other caffeinated beverages, such as soda and tea, does not seem to have the same benefit. Preventing Gallstones During Weight Loss Maintaining a normal weight and avoiding rapid weight loss are the keys to reducing the risk of gallstones.

The Effects of Cholesterol-Lowering Drugs Although it would be reasonable to believe that drugs used to lower cholesterol would protect against gallstones, evidence on gallstone protection from these drugs is mixed. Diagnosis The challenge in diagnosing gallstones is to verify that abdominal pain is caused by stones and not by some other condition.

Ruling Out Other Disorders In patients with abdominal pain, causes other than gallstones are usually responsible if the pain lasts less than 15 minutes, frequently comes and goes, or is not severe enough to limit activities.

Pancreatitis It is sometimes difficult to differentiate between pancreatitis and acute cholecystitis, but a correct diagnosis is critical because treatment is very different. Other Conditions with Similar Symptoms Acute appendicitis, inflammatory bowel disease Crohn disease or ulcerative colitis , pneumonia, stomach ulcers, gastroesophageal reflux and hiatal hernia, viral hepatitis, kidney stones, urinary tract infections, diverticulosis or diverticulitis, pregnancy complications, and even a heart attack can potentially mimic a gallbladder attack.

Physical Examination In patients with known gallstones, the doctor can often diagnose acute cholecystitis gallbladder inflammation based on classic symptoms constant and severe pain in the upper right part of the abdomen. Laboratory Tests Blood tests are usually normal in people with simple biliary colic or chronic cholecystitis.

The following blood test abnormalities may indicate gallstones or complications: Bilirubin and the enzyme alkaline phosphatase are sometimes elevated in acute cholecystitis, and in most cases of choledocholithiasis common bile duct stones.

Bilirubin is the orange-yellow pigment found in bile. High levels of bilirubin cause jaundice, which gives the skin a yellowish tone. Blood levels of liver enzymes such as alkaline phosphatase and serum transaminases are often measured. Other enzymes known as aspartate aminotransferase AST and alanine aminotransferase ALT may also be tested.

Imaging and Diagnostic Techniques Ultrasound of the Abdomen Ultrasonography Ultrasound is a simple, rapid, and noninvasive imaging technique. How well ultrasound can help in the diagnosis varies based on the patient's situation: Ultrasound accurately detects gallstones as small as 2 mm in diameter.

Some experts recommend that the test be repeated if an ultrasound does not detect stones, but the health care provider still strongly suspects gallstones. Air in the gallbladder wall may indicate gangrene.

Ultrasound does not appear to be very useful for identifying cholecystitis in patients who have symptoms but do not have gallstones.

Ultrasound is also not as accurate for identifying common bile duct stones or imaging the cystic duct. Nevertheless, normal ultrasound results, along with normal bilirubin and liver enzyme tests are good indications that there are likely no stones in the common bile duct.

Endoscopic Ultrasound In an ultrasound variation called endoscopic ultrasound EUS , the physician places an endoscope a thin, flexible plastic tube containing a tiny camera into the patient's mouth and down the esophagus, stomach, and then the first part of the small intestine.

Computed Tomography Computed tomography CT scans may be helpful if the doctor suspects complications, such as perforation, common duct stones, or other problems such as cancer in the pancreas or gallbladder.

Magnetic Resonance Cholangiography MRC , or Magnetic Resonance Cholangiopancreatography MRCP A dye is injected into the patient's veins that helps visualize the biliary tract. X-Rays Standard x-rays of the abdomen may detect calcified gallstones and gas.

In oral cholecystography, the patient takes a tablet containing a dye the night before the test. The dye fills the gallbladder, and x-ray images are taken the next day. The test has largely been replaced by ultrasound; however, it may be useful in some cases. In cholangiography, a dye is injected into the bile duct and x-rays are used to view the duct.

It is typically used during operations to provide a clear image of the biliary tract, or during ERCP. Cholescintigraphy also called Gallbladder Radionuclide Scan or HIDA scan Cholescintigraphy, a nuclear imaging technique, is more sensitive than ultrasound for diagnosing acute cholecystitis.

The procedure involves the following steps: A tiny amount of a radioactive dye is injected intravenously. This material is excreted into bile. The patient lies on a table under a scanning camera, which detects gamma radioactive rays emitted by the dye as it passes from the liver into the gallbladder.

The test can take up to 2 hours because each image takes about a minute, and images are taken every 5 to 15 minutes. Endoscopic Retrograde Cholangiopancreatography ERCP Endoscopic retrograde cholangiopancreatography ERCP was once the gold standard for detecting common bile duct stones, particularly because stones can be removed during the procedure.

Click the icon to view a cholangiogram revealing stones in the gallbladder. Treatment Acute pain from gallstones and gallbladder disease is usually treated in the hospital, where diagnostic procedures are performed to rule out other conditions and complications. There are three approaches to gallstone treatment: Expectant management "wait and see" Nonsurgical removal of the stones Surgical removal of the gallbladder Expectant Management of Asymptomatic Gallstones Guidelines from the American College of Physicians state that when a person has no symptoms, the risks of both surgical and nonsurgical treatments for gallstones outweigh the benefits.

Symptomatic Patients Gallstones are the most common cause for emergency room and hospital admissions of patients with severe abdominal pain. Results of diagnostic tests and the exam will guide the treatment, as follows: Normal Test Results and No Severe Pain or Complications Patients with no fever or serious medical problems who show no signs of severe pain or complications and have normal laboratory tests may be discharged from the hospital with oral antibiotics and pain relievers.

Gallstones and Presence of Pain Biliary Colic with No Infection Patients who have pain and tests that indicate gallstones, but who do not show signs of inflammation or infection, have the following options: Painkillers for severe pain.

NSAIDs are the first line of analgesics for biliary pain. Such drugs include diclofenac, ketorolac, and indomethacin.

They are administered in injectable or suppository forms and typically combined with spasmolytics. Opioids such as morphine or meperidine Demerol are sometimes used for acute severe pain as an alternative to NSAIDs.

Gallbladder removal. Laparoscopic cholecystectomy is the preferred treatment for symptomatic gallstones. Surgery may be delayed for some, but the risk of developing complications over time must be considered even for those with a relatively benign presentation.

A small number of patients may be candidates for stone-breaking techniques called lithotripsy, using a laser or electric charge. The treatment works best on solitary stones that are less than 2 cm in diameter. However, this therapy is associated with a high long-term recurrence rate.

Drug therapy. Drug therapy for gallstones is available for some patients who are unwilling to undergo surgery, or who have serious medical problems that increase the risks for surgery. Recurrence rates are high with nonsurgical options, and the introduction of laparoscopic cholecystectomy has greatly reduced the use of nonsurgical therapies.

Note: Drug treatments are generally inappropriate for patients who have acute gallbladder inflammation or common bile duct stones, because delaying or avoiding surgery could be life-threatening. Acute Cholecystitis Gallbladder Inflammation The first step if there are signs of acute cholecystitis is to "rest" the gallbladder in order to reduce inflammation.

This involves the following treatments: Fasting. Intravenous fluids and oxygen therapy. Combinations of strong painkillers with spasmolytics, such as ketorolac and meperidine Demerol may also be particularly useful.

Intravenous antibiotics. These are administered if the patient shows signs of infection, including fever or an elevated white blood cell count, or in patients without such signs who do not improve after 12 to 24 hours.

Click the icon to view an illustrated series on gallbladder removal cholecystectomy. Gallstone-Associated Pancreatitis. Patients who have developed gallstone-associated pancreatitis almost always have a cholecystectomy during the initial hospital admission or very soon afterward.

For gallstone pancreatitis, immediate surgery may be better than waiting up to 2 weeks after discharge, as current guidelines recommend. Patients who delay surgery have a high rate of recurrent attacks before their surgery.

Common Duct Stones. If noninvasive diagnostic tests suggest obstruction from common duct stones, the doctor will perform endoscopic retrograde cholangiopancreatography ERCP to confirm the diagnosis and remove stones.

Transoral techniques may also be performed. This technique is used along with antibiotics if infection is present in the common duct cholangitis. In most cases, common duct stones are discovered during or after gallbladder removal. Click the icon to view an image on endoscopic retrograde cholangiopancreatography ERCP.

Management of Common Bile Duct Stones Common bile duct stones pose a high risk for complications and nearly always warrant treatment.

Endoscopic retrograde cholangiopancreatography ERCP with endoscopic sphincterotomy ES is now the most frequently used procedure for detecting and treating common bile duct stones.

The procedure involves the use of an endoscope a flexible tube containing a miniature camera and other instruments , which is passed down the throat to the bile duct entrance. Laparoscopic common duct exploration has taken a secondary role in the detection and removal of common bile duct stones.

This is an approach through the abdomen, but it uses small incisions instead of one large incision. It is used in combination with ultrasound or a cholangiogram an imaging technique in which a dye is injected into the bile duct and moving x-rays are used to view any stones.

During percutaneous transhepatic cholangiography PTC , bile duct stones can also be diagnosed and removed. A needle is inserted through the skin, liver and bile duct to deliver a dye for imaging. A catheter can also be inserted to drain the bile duct.

Open surgical bile duct exploration requires a wide abdominal incision. It is not routinely performed, but may be necessary in some cases. Dissolution Therapies Oral drugs to dissolve gallstones and lithotripsy alone or in combination with medication raised hopes in the s.

Oral Dissolution Therapy Oral dissolution therapy uses bile acids in pill form to dissolve gallstones, and may be used in conjunction with lithotripsy, although both techniques are rarely used today.

There is some conflicting evidence on its effectiveness as an add-on to biliary stenting. Contact Dissolution Therapy Contact dissolution therapy requires the injection of the organic solvent methyl tert-butyl ether MTBE into the gallbladder to dissolve gallstones.

Surgery The gallbladder is not an essential organ, and its removal is one of the most common surgical procedures performed, especially on women. Open Procedures Versus Laparoscopy Open cholecystectomy involves the removal of the gallbladder through a wide 6 to 8-inch abdominal incision.

Laparoscopy has largely replaced open cholecystectomy because it offers some significant advantages: The patient can leave the hospital and resume normal activities earlier, compared to open surgery. The incisions are small, and there is less postoperative pain and disability than with the open procedure.

There are fewer complications. It is less expensive than open cholecystectomy over the long term. The immediate treatment cost of laparoscopy may be higher than the open procedure, but the more rapid recovery and fewer complications translate into shorter hospital stays and fewer sick days, and therefore a greater reduction in overall costs.

However, some experts believe that the open procedures, including small-incision mini-laparotomy cholecystectomy, are a viable alternative to laparoscopy: It is faster to perform.

It may pose less of a risk for bile duct injury compared with laparoscopy. However, open surgery has more overall complications than laparoscopy, and bile-duct injury rates with laparoscopy are declining. Compared with laparoscopy, small-incision has similar overall complication rates, as well as duration of hospital stay and convalescence.

Small-incision appears to offer the shortest surgical time and lowest cost. The type of surgery performed on specific patients may vary depending on different factors.

Appropriate Surgical Candidates Candidates for gallbladder removal often have, or have had, one of the following conditions: A very severe gallstone attack.

Several less severe gallstone attacks. Endoscopic sphincterotomy for common bile duct stones in patients with residual gallbladder stones. Cholecystitis gallbladder inflammation. Pancreatitis inflammation of the pancreas secondary to gallstone.

High risk for gallbladder cancer such as patients with anomalous junction of the pancreatic and biliary ducts or patients with certain forms of porcelain gallbladder.

Chronic acalculous gallbladder disease also called biliary dyskinesia , in which the gallbladder does not empty well and causes biliary colic, even though there are no gallstones present. The best candidates are those with evidence of impaired gallbladder emptying.

Pregnant women who have gallstones and experience symptoms are also candidates for surgery. Timing of Surgery Cholecystectomy may be performed within days to weeks after hospitalization for an acute gallbladder attack, depending on the severity of the condition.

Indications for surgery include deterioration of the patient's condition, or signs of perforation or widespread infection. The type of surgery and timing for patients with acute cholecystitis whose condition improves and who have no signs of severe complications used to be under debate.

Strong evidence now suggests that patients who have early surgery performed between 72 to 96 hours after symptoms begin have fewer complications and a lower mortality rate than those who wait to have surgery. The time spent in hospital and the associated costs are also lowered with early compared to delayed surgery.

General Outlook Although cholecystectomy is very safe, as with any operation there are risks of developing complications, depending on whether the procedure is done on an elective or emergency basis.

When cholecystectomy is performed as an elective surgery, the mortality rates are very low. Even in older people, mortality rates are only 0. Long-Term Effects of Gallbladder Removal Removal of the gallbladder has not been known to cause any long-term adverse effects, aside from occasional diarrhea.

Laparoscopic Cholecystectomy The Procedure With laparoscopy, gallbladder removal is typically performed as follows: Laparoscopic cholecystectomy requires general anesthesia, although it is now mostly done as outpatient surgery, meaning you will be discharged in less than 24 hours.

Antibiotics may be necessary to prevent or treat infection. The surgeon inserts a needle through the navel and pumps carbon dioxide gas through it to create space in the abdomen.

One 10 to 12 mm about one-half inch and two to three 5 mm about one-fifth of an inch incisions are made in the abdomen. This is often referred to as 4 port laparoscopic cholecystectomy 4PLC.

The surgeon inserts a laparoscope a thin fiber optic scope , which contains a small surgical instrument and a tiny camera that relays an image to a video monitor.

The surgeon separates the gallbladder from the liver and other areas, and removes it through one of the incisions. Often patients will need to stay in the hospital overnight. However, some patients can go home the same day. Robot-Assisted Surgery Laparoscopic surgery may be performed using tiny keyhole incisions and 3 to 4 tiny robotic arms.

Other reasons for conversion from laparoscopic to open surgery include: Possible or known injury to major blood vessels Internal structures are not clearly visible Unexpected problems that cannot be corrected with laparoscopy Common bile duct stones that cannot be removed with laparoscopy or subsequent ERCP Previous endoscopic sphincterotomy A thickened gallbladder wall Complications and Side Effects of Surgery Pain and fatigue are common side effects of any abdominal surgery.

Patients should avoid light recreational activities for about 2 days and from work and more strenuous activities for about a week. There is a relatively high incidence of nausea and vomiting after laparoscopic cholecystectomy, which can be treated with injections of metoclopramide or Metozolv ODT by mouth.

Patients may take anti-nausea medications such as granisetron before surgery to help prevent these effects. Local anesthesia at the incision sites in addition to general anesthesia before surgery may reduce pain and nausea afterward. Injury to the bile duct is the most serious complication of laparoscopy.

It can include leakage, tears, and the development of narrowing strictures that can lead to liver damage. In order to minimize such injuries, some experts recommend that surgeons perform laparoscopy with cholangiography. With this procedure, dye is injected into the bile duct, and moving x-rays are used to view the duct.

Bile duct injury has been a more common problem in laparoscopy compared to the open procedure, but increasing surgical experience and the use of cholangiography is reducing this complication.

Studies are reporting more comparable rates between the 2 procedures. In a small percentage of these cases, the stones cause obstruction, abscesses, or fistulas small channels that require open surgery. As with all surgeries, there is a risk for infection, but it is very low.

Open Cholecystectomy Before the development of laparoscopy, the standard surgical treatment for gallstones was open cholecystectomy surgical removal of the gallbladder through an abdominal incision , which requires a 6 to 8-inch incision and leaves a large surgical scar.

Candidates for whom cholecystectomy may be a more appropriate choice: Patients who have had extensive previous abdominal surgery Patients with complications of acute cholecystitis such as empyema, gangrene, and perforation of the gallbladder Small-Incision or Mini-Laparotomy Cholecystostomy Mini-laparotomy cholecystostomy uses small abdominal incisions but, unlike laparoscopy, it is an "open" procedure, and the surgeon does not operate through a scope.

Older Patients Patients who are over 80 years old are likely to have lower complication rates from open cholecystectomy than laparoscopy, although laparoscopy may also be appropriate in these patients.

ERCP with Endoscopic Sphincterotomy ES Reasons for performing the procedure: Before gallbladder surgeries, when there is a strong suspicion that common bile duct stones are present.

At the end of a cholecystectomy, if the surgeon detects stones in the common bile duct only if there are experts in ERCP present, and equipment is available. For patients with gallstone cholangitis serious infection in the common bile duct. In such cases, urgent ERCP and antibiotics are required.

When acute pancreatitis is caused by gallstones, urgent ERCP, along with antibiotics, may be used. The use of ERCP compared to conservative treatment has been controversial. The ERCP and ES Procedure A typical ERCP and endoscopic sphincterotomy ES procedure includes the following steps: The patient is given a sedative and asked to lie on their left side.

An endoscope a tube containing fiber optics connected to a camera is passed through the mouth and stomach and into the duodenum top part of the small intestine until it reaches the point where the common bile duct enters.

This does not interfere with breathing, but the patient may have a sensation of bloating. A thin catheter tube is then passed through the endoscope. Contrast material a dye is injected through the catheter into the opening of the duct.

The dye allows x-ray visualization of the biliary tree the system of ducts through which bile flows, including the common bile duct and any stones contained in the area.

Instruments may also be passed through the endoscope to remove any stones that are detected. The next phase of the procedure is known as endoscopic sphincterotomy ES.

It is also sometimes referred to as papillotomy, although this is a slightly different variation. ES widens the junction between the common bile duct and intestine the ampulla of Vater so that the stones can be extracted more easily.

With ES, a tiny incision is usually made in the opening of the common bile duct and through the muscles that enclose the lower common bile duct the sphincter of Oddi.

One recent alternative to ES is the use of a small inflatable balloon a procedure known as endoscopic balloon dilation that opens up the ampulla of Vater to allow stones to pass.

This variation does not involve cutting muscles, and offers a lower risk of bleeding and injury to internal structures. However, this carries a higher risk for pancreatitis.

Once the junction has been opened, the stones may pass on their own, or they may be extracted with the use of tiny balloons, or sometimes baskets. Younger adults are at higher risk than older people.

The risk is also higher with more complex procedures. Postoperative infection. Antibiotics may be given before the procedure to prevent infection, although one study reported that they had little benefit. There is an increased risk for bleeding in patients taking anti-clotting drugs, and those who have cholangitis.

This complication is treated by flushing the area with epinephrine. Perforations rare. Long-term complications include stone recurrence and abscesses. Larger bile duct stones 10 to 15 mm are more difficult to remove and often require additional procedures.

Open or Laparoscopic Common Bile Duct Exploration Choledocholithotomy Laparoscopic Exploration and Cholangiography Surgeons are now increasingly using laparoscopy with cholangiography instead of ERCP when common duct stones are suspected.

This procedure should be done for the following reasons: As an alternative to ERCP before gallbladder surgeries, when there is a high suspicion of common bile duct stones. During gallbladder surgeries when common duct stones are detected or highly suspected.

The procedure usually involves the following steps: The initial approach is the same as with laparoscopic cholecystectomy. One or two 10 to 12 mm around one half an inch incisions and three 5 mm about one-fifth of an inch incisions are made in the abdomen.

A tiny opening is made in the cystic duct that connects the gallbladder to the bile duct, and a thin tube is introduced to perform a cholangiography.

If stones are identified, the surgeon inserts a tube with an inflatable balloon to widen the duct. Stones are usually retrieved or withdrawn from the duct with either a balloon or tiny basket. If laparoscopy is unsuccessful, ERCP or open surgery is performed.

Open Common Bile Duct Exploration Choledocholithotomy Choledocholithotomy, or common bile duct exploration, is used: To remove large stones. When the duct anatomy is complex. During or after some gallbladder operations when stones are detected.

If the procedure is being performed laparoscopically, the surgeon may convert to an open procedure, though this happens less often now. When ERCP or laparoscopic procedures are not available. Extracorporeal Shock Wave Lithotripsy Gallstone fragmentation by extracorporeal shock wave lithotripsy ESWL may be an appropriate therapy for some patients with pain, normal gallbladder emptying, and no other complications, but it is no longer widely used.

We aimed to investigate whether visceral fat measured by computed tomography CT is a risk factor for gallstone disease. Methods: A cohort of participants undergoing CT and ultrasonography was analyzed. The associations between body mass index BMI , visceral adipose tissue VAT area, subcutaneous adipose tissue SAT area, and gallstone disease were analyzed adjusted for age, sex, hypertension, diabetes, and dyslipidemia.

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Does body mass index adequately capture the relation of body composition and body size to health outcomes? Regulation of the diurnal rhythm of rat liver beta-hydroxy-beta-methylglutaryl coenzmye A reductase activity by insulin, glucagon, cyclic AMP and hydrocortisone.

Gallstone disease risk in relation to body mass index and waist-to-hip ratio in Japanese men. Leptin-resistant obese mice have paradoxically low biliary cholesterol saturation.

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Defects in High Density Lipoprotein metabolism and hepatic steatosis in mice with liver-specific ablation of Hepatocyte Nuclear Factor 4A. Karger AG, Basel. Copyright: All rights reserved.

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