Stone Age

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It is estimated that between 10 to 15 percent of the adult U.S. population has gallstones. Most cases are asymptomatic, as gallstones are usually discovered incidentally during routine imaging for other abdominal conditions. Only about 20 percent of those with gallstones ever develop clinically significant complications. Be that as it may, gallstones account for significant healthcare costs. In 2004, the average inpatient cost for any gallstone-related disease was $11,584, with an overall annual cost of $6.2 billon.

Gallstones are classified into two main categories based on their predominant chemical composition: cholesterol or pigment. About 75 percent of gallstones are composed of cholesterol. There are multiple risk factors for the development of gallstones. These include age above 40, female sex (women of reproductive age are four times more likely to develop gallstones than men, although this risk evens out after menopause), ethnicity (highest in Mexican and Native Americans), rapid weight loss (especially after weight-loss or bariatric surgery), chronic blood disorders that cause hemolysis (the breakdown or rupturing of red blood cells), obesity, and diabetes. Most patients with gallstones never experience symptoms. In those who have symptoms, the most common one is abdominal pain. The pain is usually intermittent and occurs in the right upper abdomen. There may be pain in the upper mid-abdomen, back, and right shoulder. The pain is caused by distension of the gallbladder because a stone is blocking the cystic duct. In response to a meal, the gallbladder contracts and pushes bile out via the cystic duct into the common bile duct and intestines. Pain an hour or so after a meal or in the late evening or night is strongly suggestive of gallstones.

Annually, about one to three percent of those with gallstones experience a complication. Complications can include cholecystitis (acute gallbladder inflammation), choledocolithiasis (common bile duct stone), cholangitis (gallbladder infection), and pancreatitis. A sonogram is usually the test of choice to diagnose gallstones. Other tests can be used as the clinical situation warrants. The standard treatment of asymptomatic gallstones is watch and wait. Studies have shown that those with asymptomatic gallstones have about a seven to 26 percent lifetime risk of developing complications. Surgery to remove asymptomatic gallstones is not recommended, except in certain situations. These situations include those with hemolytic anemias (i.e. sickle cell disease) and patients who are Native Americans. Calcification of the gallbladder wall can occur (“porcelain gallbladder”). This occurrence was, but no longer is, an indication to remove the gallbladder. Also, removal of the gallbladder was routinely performed during bariatric (weight-loss) surgery, but that is no longer the case. For those who have gallstone symptoms or complications, laparoscopic cholecystectomy is the procedure of choice. In general, laparoscopic surgery has a shorter recovery time and patients spend less time hospitalized.

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