Tombstones of digestion

No one can digest ‘indigestion’. Gallstones are often blamed as a cause for indigestion. Actually, gallstones are formed in the gall bladder due to indigestion or a defective digestive process. The liver excretes (bile pigments) and secretes (bile salts) as yellowish green bile in a continuous process and drains it through the hepatic duct into the small intestine. Most of the bile gets back into the gall bladder (for storage) via the cystic duct due to closure of the sphincter in the intestinal wall. The gall bladder is a small, pear-shaped pouch or sac present adjacent and under the liver surface for storing the bile. The stored bile is concentrated in the gall bladder to about 10 times and poured into the duodenum by periodical contraction of the gall bladder i.e. after ½-1 hour of food intake or when required, through the common bile duct. The gall bladder can store 50-60 ml of bile. Normally, bile flows at the rate of 40-50 ml/hour. The bile stagnation or its composition ratio difference or an infection in the gall bladder can cause stone formation i.e. gallstones.

Bile secreted by the liver is alkaline in nature (pH - 7.5-8.5) and it is mostly composed of 97 per cent water and rest of it consists of conjugated bile salts (sodium and potassium salts of bile acids), cholesterol, lecithin (phospholipids), bilirubin (pigment), and electrolytes. Bile neutralises the acid food which comes from the stomach and also helps to alkalinise the intestine. It plays a major role in emulsification, absorption and digestion of the fat and oil of our foods. It is a very good natural laxative for the colon. So, only in the case of obstructive common bile duct or liver disorders will there be constipation. The bile salts are important for removal of cholesterol from our body. It combines with lecithin and cholesterol to form micceles which is excreted normally in the stool. Sometimes, bile crystallises in the gall bladder, due to various reasons, forming gallstones.

Incidence of gallstones - The incidence of gallstone formation is increasingly seen in the fourth decade of life, especially in women of obese constitution with high cholesterol level. Also women under contraceptive pills, sedentary lifestyle, multi-para women, and people suffering from chronic ulcerative colitis are major victims. The increased dietary intake of fast foods, pastries, oily, spicy foods can cause gallstones more. Even though it can occur in men, its incidence is more commonly seen in fat, fertile, flatulent and women in their forties. Gallstones are mostly seen in the body of the gall bladder rather than in the common bile duct or in the pouch in the neck of the gall bladder.

Gallstones are usually soft and vary in size, shape, number and types.

• Size of the stone - varies from 5 mm to 2 cm
• Shape varies from round, oval to irregular
• Number of stones may vary from single or solitary to tiny 100s
• Types - The stone types can be classified by two methods, one by its composition and another by its origin. Mostly, it is classified as septic stones and septic stones.

Aseptic stones are

Pigment stones – dark green in colour, small in size, usually multiple and irregular in shape. They are usually seen inside the gall bladder and rarely in the common bile duct. They are formed due to blood disorders like haemolytic jaundice, chronic myeloid leukemia (blood cancer) and other chronic infections which maintain the erythrocyte sedimentation rate (ESR) at a high level. These conditions, due to blood destruction, cause increased serum bilirubin level. These bilirubins are trapped in the liver and excreted in the bile. If the bile doesn’t flow properly, these pigments accumulate as sediment and form stones.

Cholesterol stones are yellow in colour and usually seen in singles. It is oval in shape, soft in consistency and smooth. This type of stone is usually seen in the hartmann’s pouch in the neck of the gall bladder since these types of stones usually float.

Septic stones are more than aseptic stones.

Mixed stones are brown in colour, large in size, usually multiple and irregular in shape. These types constitute 70-80 per cent of stones. These stones are composed of cholesterol, pigments, salts and other chemicals. Since it is somewhat larger in size, it is usually seen in the body of the gall bladder as it cannot escape into the intestine and outweigh the risk of blockage in the common bile duct.

Causes of gallstones - Mainly, stagnation of bile in the gall bladder or duct for a prolonged time evokes stone formation as the outcome of precipitation or sediment. It may also be due to variation in concentration ratio of cholesterol with bile salts (normal it is 1:20-1:30) in the bile. In general, routine causes are

• Functionless gall bladder i.e. thick walled gall bladder with no contraction at all
• Untimely, unconditioned diet and starvation often. Also reduced food intake can reduce the secretion of bile acids from the liver. This causes difference in composition ratio of bile salts and cholesterol, which finally results in cholesterol stones.
• Prolonged use of drips, by avoiding oral foods in case of hospital stay
• Fatty, flabby belly and pregnancy can relax the gall bladder and thus cause stones
• Malfunctioning of liver which secretes less bile with less bile salts
• Infection of gall bladder (acute or chronic cholecystitis)
• Injury in the gall bladder area which causes inflammation of gall bladder
• Taking non-veg foods, fast foods, pastry, oily and spicy foods often.
• Increased blood cholesterol level
• Diseases of the intestines - for example, ulcerative colitis, crohn’s disease, irritable bowel syndrome, etc. Here, absorption of bile salts from the intestine or recycling of bile salts is interrupted, so the liver secretes bile containing very low bile salts. These lowered bile salts can’t maintain the cholesterol in solution, forming cholesterol gallstones.

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