No, this is not some twisted personal want-ad! This is the classic “four F’s” description of patients most at risk for developing gallbladder disease, as taught to all medical students. During their reproductive years, women are 2-3 times more likely than men to develop gallstones. Gallstones form when bile substances (mainly cholesterol and calcium bilirubinate) concentrate and form crystals, which coalesce over time to form stones.
During their reproductive years, women are 2-3 times more likely than men to develop gallstones.
The gender disparity is likely due to the influence of estrogen, which increases the concentration of biliary cholesterol secretion. Furthermore, the high progesterone levels occurring during pregnancy reduce gallbladder contractility, which leads to prolonged retention and concentration of bile in the gallbladder. Obesity (the fifth “F”) and the associated syndrome of type II diabetes, hyperlipidemia, and hypertension is a major risk factor for the development of gallbladder disease, which appears to be due to increased liver secretion of cholesterol.
Gallstones may not result in any symptoms as long as they do not obstruct the gallbladder. Symptoms can be episodic as the stones fall into the pathway of the gallbladder’s emptying by occluding the cystic duct.
“Biliary colic” ensues if obstruction of the gallbladder occurs from a stone while the gallbladder is contracting, with painful episodes of right upper quadrant pain lasting 30-90 minutes. This may be accompanied by nausea, vomiting, and sweating (diaphoresis). Other symptoms may include belching, bloating, upset stomach, and fatty food intolerance (which is a strong stimulator of gallbladder contraction). Persistent obstruction of the gallbladder can lead to acute cholecystitis. In acute cholecystitis, the gallbladder becomes inflamed and infection can develop. Further complications may include pancreatitis, infection of the biliary ducts, and jaundice due to biliary obstruction. The diagnosis of gallbladder disease and potential complications is usually made with a combination of clinical examination, laboratory studies, and gallbladder ultrasound. An ultrasound evaluation of the gallbladder is very useful for identifying the presence of gallstones and may also be useful to identify acute cholecystitis. Another potentially useful imaging test in patients suspected of having gallbladder disease is the HIDA scan. The HIDA scan is a nuclear medicine exam in which a very tiny and safe dose of radioactive substance is given intravenously and the patient is subsequently imaged from the inside out, so to speak. The HIDA scan lets doctors know if the liver and gallbladder are functioning properly, if the main bile duct is open, and if the duct leading to the gallbladder is open. MRI may be useful in some cases to identify potentially obstructing stones in the bile ducts.
For patients diagnosed with gallbladder stones but no symptoms, medical management (nonsurgical) is the usual approach. This can include strategies to decrease bile concentration to reduce stone formation. If stones are large, cholecystectomy may still be indicated. For symptomatic gallbladder disease, the procedure of choice is cholecystectomy. This is usually performed through small incisions laparoscopically. Some individuals may require open surgical removal of the gallbladder.