How do I recognize gallbladder problems

Problem case bile


From cholesterol and pigment stones

Gallstones are one of the women's ailments. The female sex is two to three times more likely to be "filthy rich" than people of the same age. In the more favorable case, gallstones can be located in the gallbladder, in the worse case in the bile ducts. They occur when the bile is oversaturated with calcium, cholesterol and bilirubin. Up to 90% of gallstones are pure (10%) or mixed cholesterol stones. They crystallize in the gallbladder, but can also get into the biliary tract from there. If the cholesterol content is below 50% and the bilirubin content is over 25%, one speaks of pigment stones. They consist of calcium bilirubinate, calcium carbonate, calcium phosphate or calcium palmitate.


Cholecystolithiasis: "very rich" gallbladder

Cholecystolithiasis is common with a prevalence in Germany of 10 to 15% and an incidence of 600 per 100,000 inhabitants per year. The most important risk factor is obesity. The risk also increases with age, as bile production and flow decrease. The symptoms are typical: biliary colic with postprandial pain in the right upper abdomen, which occasionally radiates to the shoulder and back. Some patients complain of nausea and vomiting. However, only about 20% of gallstone carriers are symptomatic. The rest are symptom-free. Dyspeptic symptoms such as heartburn, belching, nausea and fat intolerance can indicate gallstones. No treatment is indicated for asymptomatic gallstones diagnosed by chance. However, up to a third develop symptoms in the further course. Acute biliary colic is treated with antispasmodics and highly effective analgesics. Then the gallbladder is usually removed laparoscopically. Extracorporeal shock wave lithotripsy (ESWL), oral lysis or even percutaneous transhepatic contact lysis are rarely used. With these procedures, the gallbladder is preserved and with it the risk of stone formation again. On the other hand, there are no disadvantages to living without a gallbladder. The bile that is formed then flows directly into the small intestine without being temporarily stored in the gallbladder. Diarrhea is only possible in the first time after the operation. No special diet is required. However, excessive amounts of fat can be unfavorable.

Choledocholithiasis: blocked bile ducts

Very few gallstones that are stuck in the bile ducts also arise there. Much more often they migrate from the gallbladder and then get stuck in the bile ducts or in the pancreatic duct. Such secondary gallstones are cholesterol stones or black pigment stones. When gallstones develop in the bile duct, there is usually an infection behind them. The pigment stones are then brownish in color. Bile duct stones cause symptoms far more often than gallbladder stones. They can trigger inflammation that stenoses the duct even after the stone has long since come off. Acute pancreatitis is also possible if the location is appropriate. Jaundice, a consequence of the obstructed or stenosed bile duct, and biliary colic are the characteristic symptoms. Bile duct stones must always be treated. The endoscopic papillotomy is the standard procedure. The papilla vateri is cut through and the stone is removed. Mechanical and chemical litholysis, extracorporeal shock wave lithotripsy and laser lithotripsy are also possible.

Cholecystitis: inflammation of the gallbladder wall

If the gallbladder outlet is blocked by a stone, the risk of inflammation of the gallbladder wall is high. The thickened bile damages the mucous membrane with bile acids and lysolecithin and stimulates an inflammatory process. Cholecystitis starts suddenly and causes severe pain in the upper right abdomen. Nausea and vomiting can also occur. If germs migrate into the gallbladder, serious complications can occur. After several acute inflammations, chronic cholecystitis with recurrent pain attacks can develop. Gallbladder inflammation is treated as an inpatient with bed rest, strict abstinence from food and parenteral fluid supply. Spasmolytics, analgesics and antibiotics are used as medication. Conservative therapy is basically possible. However, due to the high risk of recurrence and possible complications, early cholecystectomy under antibiotic protection is recommended. This also applies to chronic cholecystectomy, which is usually asymptomatic with frequent dyspeptic symptoms. It can develop into a shrinking gallbladder or a porcelain gallbladder, 25% of which ends in a carcinoma.

Cholangitis: Away with the stone

Cholangitis is an inflammation of the biliary tract, usually caused by bacteria, with fever, jaundice and pain. The causes are usually gallstones, which incompletely obstruct the biliary tract and thus clear the way for bacteria from the intestine. The therapy is obvious: the stone must be removed, usually through a papillotomy with stone extraction. Only rarely does a tumor or, in Germany a rarity, a parasite narrow the bile duct.

Rare: malignant tumors

Benign tumors of the gallbladder are common. On closer inspection, these are mainly gallbladder polyps. Only about 4% are true adenomas. These benign lesions are incidental findings and usually asymptomatic. The recommendation for therapy is therefore "no surgery". A cholecystectomy can only be considered in the case of large polyps or colic-like symptoms.

In malignant tumors, gallbladder carcinoma is more common than bile duct carcinoma. It is the sixth most common gastrointestinal cancer. Gallstones are also found in three quarters of these patients. It is unclear whether they cause the tumors. What is certain, however, is that there is an increased risk of cancer in chronic cholecystitis with porcelain gallbladder. Jaundice, abdominal pain and colic characterize the symptoms. The therapy of choice is surgery. Radiation and chemotherapy are not very successful. The prognosis is poor with mean survival less than six months. Bile duct carcinomas occur more frequently in chronic inflammation of the bile ducts such as primary sclerosing cholangitis. Typical is a painless jaundice with itching, stool discoloration and weight loss. Here, too, the prognosis is poor: two thirds of the patients are already inoperable at the time of diagnosis.

"I've got it in the bile"

Many customers come to the pharmacy with this cry for help. When asked specifically, it usually covers the whole range of dyspeptic complaints: digestive disorders, heartburn, nausea, diffuse upper abdominal complaints or meteorism. Indigestion of the bile dysfunction with reduced bile flow is indigestion with discomfort in the right upper abdomen, especially after fatty meals. A change in diet is therefore a measure against recurring biliary problems. Low-fat and low-cholesterol foods should be preferred and high-fat foods should be avoided. The flow of bile can be stimulated with herbal choleretics. Extracts from artichoke leaves, milk thistle fruits, dandelion herb or Javanese turmeric are often used. However, such preparations are contraindicated when the biliary tract is blocked! As a precaution, patients with "gallbladder disease" should therefore consult their doctor at an early stage. However, all preparations that stimulate the flow of bile can also cause biliary colic themselves or worsen existing colic. If it is already known that the patient has gallstones, choleretics may only be used after consultation with a doctor!



Internal medicine (Eds. Berdel, Böhm, Classen, Diehl, Kochsiek, Schmiegel) 5th edition. Urban & Fischer, Munich, Jena (2003).

MSD Manual Handbuch Gesundheit (Ed. Mark H. Beers) Originally published by Merck research Laboratoires, NJ (USA); in Germany: Goldmann Verlag, Munich.

12th Symposium Current Hepatology 2006, Wiesbaden, organized by the Falk Foundation e.V., Freiburg.


Author's address:

Pharmacist Dr. Beate Fessler

Karwinskistr. 40

81247 Munich