Gallstones – Types, Causes, Risks, Symptoms, Treatments

        Gallstones - Types, Causes, Risks, Symptoms, Treatments  Gallstones

 What is gallstone?

Gallstones are small stone like structures develop abnormally from the sediments (deposits) of bile (digestive fluid) in the gallbladder.

Gallstones are otherwise called as Cholelithiasis.

Gallbladder is a small pouch (bag) like organ found below the liver where bile is stored.

Causes of gallstones

When more bile is secreted by the liver or when the emptying of bile from the gallbladder is poor, the bile gets concentrated and become gallstone.

The common causes may be genetic, obesity (sudden increase or drastic loss of weight), using birth control pills, hormone replacement therapy, cholesterol medications, diabetes, pregency and eating lots of fried and processed foods. Hemolytic anemia and infection can also cause gallstones.

Gallstones are usually found in Fat, Fair, Fertile, Female of Forty with Family history of gallstones.(rule of F)

Types of gallstones

Cholesterol Stones

They are white, yellow or green in color and few in number. They may form up to 3 cm in size.

They are common and 80% of its contents are cholesterol.

Bilirubin Stones

Bilirubin Stones are darker and smaller in size and numerous in numbers. They are made up of mainly bile pigments and calcium.

Mixed Stones

They are made up of cholesterol, bile pigments and calcium.

Symptoms and Signs of gallstones

Normally Gallstones are painless. But pain starts when the stone enters the bile ducts and produce obstruction of bile flow.

Pain is usually felt in the upper portion of abdomen on the right side.( Right hypochondriac region). Pain may be felt just below the breastbone (Epigastria). Pain may also be referred to the right shoulder. Pain may be associated with nausea and vomiting. Stones in common bile duct can produce obstructive jaundice.

Murphy’s sign: When deep palpation is done just below liver (right upper abdomen below rib cage) and the patient in deep inspiration, the patient may feel severe tenderness. Pain is produced when the inflamed gallbladder come in contact with the hand.

Tests (investigations) done

As most of the gallstones are symptomless, they are diagnosed while doing investigations for other diseases.

X-ray chest

some gallstones are not visible on X-rays. Only radio-opaque stones are seen through x-rays.

Ultrasonogram (USG)

This is cheaper and noninvasive and investigation of choice for gallstones.

MRI (Magnetic Resonance Imaging)

MRI gives clear detailed images of the gallbladder, bile ducts and liver. It gives images of gallstones and dilatation of bile ducts.

MRCP (Magnetic Resonance Cholangiopancreatography)

Can visualize the biliary tree and gallstones.

ERCP (Endoscopic Retrograde Cholangiopancreatoscopy)

Here a flexible (Fibro optic ) endoscope is passed through the mouth, oesophagus and stomach to reach the duodenum. A dye is injected into the bile duct and scanning done and images are taken to visualize gallstones and biliary tree. Stones can be removed through ERCP.

PTC (Percutaneous Transhepatic Cholangiography)

Through a small incision in the skin of right upper abdomen and contrast material is passed into the biliary tree and images taken. Gallstones can be removed using PTC.

Blood Investigations

Blood tests like Liver function tests(LFT) and Pancreatic Amylase are done to rule out liver and pancreatic damage. Routine Blood tests are done to rule out other associated diseases.

Treatment for Gallstones

Most gallstones are painless, but when the pain is severe treatment is necessary.

Pain Killers: When the pain is severe, painkillers like antispasmodics, NSAIDS    ( non-steroidal anti-inflammatory drugs) or opiates can be given.

Antibiotics are given to prevent cholecystitis.

Cholecystectomy (surgical removal of gallstones and gallbladder) is the treatment of choice. This can be done through open surgery or through Laparoscope.

ERCP or PTC: Gallstones can also be removed through ERCP or PTC.

Lithotripsy: Here ultrasound shock waves are used to break gallstones into small fragments, which can be drained through bile duct into small intestine.

Medical Treatment: When the patient has severe comorbid diseases, medical treatment to dissolve gallstones were given.

Ursodeoxycholic acid can be given for a long period to dissolve cholesterol gallstones.

Chronic Obstructive Pulmonary Disease (COPD)

Chronic Obstructive Pulmonary Disease (COPD)

Chronic Obstructive Pulmonary disease (COPD) is a slowly progressing, long time disease of the lungs which produce obstruction of the airway which is not fully reversible.(complete recovery is not possible with or without treatment.)

COPD is a preventable disease

COPD is the third leading cause of death (In 1990 it was the sixth leading cause death) in the world.

Causes of COPD

COPD is mainly caused by longtime tobacco smoking (80%). Both active and passive (second-hand smoke) can produce COPD.

Long time exposure to other smoke, dust, chemicals and other types of pollution can also produce COPD.

In women, cooking with biogas or firewood in the poorly ventilated kitchen can also produce COPD.

Long drawn (Chronic) poorly treated diseases like Asthma and tuberculosis can also become COPD.

Congenital (hereditary) absence or deficiency of Alpha1antytripsin can also produce COPD.

Types of COPD

In COPD there are 2 types.

Chronic Bronchitis

When the patient suffers from cough for more than three months in a year, for two or more continuous years, the patient is said to be suffering from Chronic Bronchitis.

Pathology of Chronic Bronchitis

In Chronic bronchitis, due to long-time exposure to smoke the bronchial wall becomes thick (bronchial wall hypertrophy) and the inflammation and increased mucus secretion narrow the airway producing wheezing. As there is not much bronchial constriction, improvement after bronchodilators in minimal or nil (not fully reversible) unlike Asthma where bronchial constriction is relived after medication.

Emphysema

Destruction of elastic property of the alveoli leading to shortness of breath.

Pathology of Emphysema

In a normal person, the amount of Alpha1 antitrypsin and the protease enzyme Elastase are equal. Alpha 1 antitrypsin will neutralize the action of elastase.  When the person smokes, the neutrophils produce more Elastase, and the extra elastase produced will destroy the elastic property of the alveoli. This leads to overinflation of the alveoli with each inspiration. Over-inflation of alveoli leads to the destruction of alveolar membrane and few alveoli may burst together to become a bulla. Air becomes trapped in the alveoli and perfusion and ventilation are affected.

Symptoms of COPD

Cough for more than three months,

Slowly progressing difficulty in breathing (dyspnoea),

Mucus production,

Wheezing, Tightness in the chest.

Signs of COPD

Patient may have shortness of breath, Respiratory rate increased,

May have barrel chest (In Emphysema),

Lip & tongue may become blue (cyanosis)

Breath sounds may be diminished (emphysema) or may have wheeze (chronic bronchitis)

Tests to be done in COPD

Spirometry (pulmonary function test) is done to differentiate between Asthma and COPD.

Spirometry is done, then inhaled bronchodilators are given to the patient and spirometry is repeated again to note the reversibility. If FEV1 is less than 80% of normal, there is obstruction and improvement after broncho-dilator is less than 12% it is COPD.

X-ray chest- may show hyperinflated lungs with flat diaphragms and narrow heart.

ECG is taken to rule out Cor- Pulmonale (Heart involvement due to long-standing respiratory disease.)

ABG (Arterial Blood Gas Analysis) done to find the blood gas levels.

Stages in COPD

According to the PFT (pulmonary function test) reading, the severity of COPD is divided into 4 stages.

Mild: if the FEV 1 (forced expiratory volume in 1 second) is above 80 % of the predicted value and the FEV1/FVC (Forced vital capacity) is less than 0.7  and the reversibility is less than 12% it is termed as mild COPD.

Moderate:  FEV 1 – between  80 %  and 50 %.

Severe:  FEV 1 – less than 50 %.

Acute Exacerbation of COPD

When there is a sudden flare-up of symptoms due to infection or exposure to irritants patient may have severe shortness of breath. Hospitalization may be necessary with oxygen therapy and antibiotics.

Treatment of COPD

The main aim of the treatment is to relieve shortness of breath and improve the respiratory functions.

This will improve quality of life of the COPD patient and make him live independently in this society.

The Treatment regimen is like that of Asthma. Bronchodilators and anti-inflammatory drugs (Steroids) are given and they are not very effective as COPD is not fully reversible.

Bronchodilators like salbutamol, levosalbutamol, salmeterol and formoterol reduce the bronchospasm.

Anticholinergics like tiotropium, ipratropium, albuterol and aclidinium dilate the bronchus and reduce the secretions.

Steroids like fluticasone, budesonide, and beclometasone deduce swelling of the bronchial wall and mucous membrane.

Inhaled medicines (Inhalation therapy) are best for COPD and Asthma than oral medicines or injections.

Inhalers having beta-agonists and anticholinergics (2 drugs) or 3 drugs combination along with steroids are used.

In Acute Exacerbation, Oxygen therapy and antibiotics along with inhalation therapy are given.

Mucolytics and Expectorants are given to bring out excess mucus from the airway.

Long-term oxygen Therapy: For severe COPD patients Long time oxygen therapy is given using an oxygen concentrator.

Roflumilast: a phosphodiesterase 4 inhibitor is given to reduce inflammation and to improve the FEV1.

Vaccines: Influenza vaccination and pneumococcal vaccine are given to elderly patients to prevent exacerbations.

Alpha 1 Antitrypsin augmentation (replacement) therapy is given in patients with congenital Alpha 1 Antitrypsin deficiency.

Smoking Cessation: Smoking cessation will stop the progression of the disease. This involves psychological counseling, health education, nicotine replacement therapy (like nicotine patches and nicotine chewing gum).

Medicines like varenicline, Bupropion and nortriptyline are given to stop smoking.

Antidepressants to relieve mental depression associated with COPD.

Surgical Treatment: In severe conditions, surgical treatment like Lung volume reduction surgery, Bullectomy or Lung transplantation may be necessary.

Rehabilitation: Rehabilitation of COPD patients involves treatment by pulmonologist, physician, psychologist, respiratory therapist and occupational therapists. The Rehabilitation program helps the patient live independently in the society.