Gallstones are hardened deposits of digestive fluid that can form in the gallbladder, a condition known as cholelithiasis. They are a common complication of inflammatory bowel disease (IBD), sometimes referred to as an extraintestinal manifestation. Individuals with Crohn’s disease face twice the risk of developing gallstones compared to the general population, while those with ulcerative colitis also have an increased risk.
Understanding the Gallbladder and Gallstones
The gallbladder is a small organ located in the upper right area of the abdomen, connected to the liver. It stores bile, a fluid produced by the liver containing bile acids, bile salts, cholesterol, and bilirubin. After eating, the gallbladder releases bile into the small intestine through biliary ducts to aid in fat breakdown and absorption.
Gallstones are solid formations in the gallbladder, primarily composed of cholesterol or bilirubin. They vary in size, ranging from small grains to larger apricot-sized stones.
Gallstone Formation: Causes and Contributing Factors
While the exact causes of gallstone formation are not fully understood, three main factors contribute to their development:
- Too Much Cholesterol: An overabundance of cholesterol that bile salts cannot absorb can lead to crystallization and the formation of yellow-green cholesterol gallstones, which constitute 90% of all gallstones.
- Too Much Bilirubin: Certain medical conditions, like cirrhosis or sickle cell anemia, can cause the liver to produce excess bilirubin, resulting in the formation of dark-colored gallstones.
- The Gallbladder Doesn’t Empty Correctly or Completely: When bile isn't fully cleared from the gallbladder, it becomes concentrated, increasing the risk of gallstone formation.
Recognizing the Symptoms of Gallstones
Most individuals with gallstones remain asymptomatic, a condition known as silent gallstones. However, about 20% of people with gallstones will experience symptoms, with pain being the most common. When gallstones obstruct a biliary duct, they block the flow of bile, causing the gallbladder to spasm, resulting in a gallbladder attack or biliary colic.
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Symptoms of a gallbladder attack vary from person to person but often include:
- Abdominal pain in the upper right or mid-abdomen, lasting from minutes to hours
- Vomiting
- Shoulder or back pain
- Fever
- Pale stools
- Yellow tint to the eyes or skin (jaundice)
If you experience any of these symptoms, seek immediate medical attention.
Diagnosing Gallstones
Gallstones are diagnosed through a medical history review, physical examination, blood work, and imaging studies. Ultrasound is the preferred imaging method for diagnosing gallstones. Other imaging procedures, such as computed tomography (CT) scans, magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), cholescintigraphy scans, or endoscopic retrograde cholangiopancreatography (ERCP), may also be used.
Diagnosing gallstones can be more complex in individuals with IBD due to the overlapping symptom of upper abdominal pain in both conditions.
The Connection Between Gallstones and IBD
While Crohn’s disease and ulcerative colitis don't directly cause gallstones, they can increase the risk due to chronic inflammation in the gallbladder (cholecystitis). Crohn’s disease is associated with a higher risk of gallstone formation compared to ulcerative colitis.
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Gallstone incidents increase with:
- Inflammation of the small intestine
- Duration of Crohn’s disease
- Number of hospitalizations
- Intravenous nutrition delivery
- Length of small intestine resection
Inflammation of the terminal ileum (the end part of the small intestine) in Crohn’s disease impairs the normal absorption of bile salts and acids, leading to excessive cholesterol accumulation in the gallbladder and stone formation.
Having Crohn’s disease for more than 15 years increases the risk of gallstones. Similarly, multiple hospitalizations for Crohn’s disease and increased frequency of parenteral nutrition are associated with a higher chance of gallstone formation. Resection of at least 30 centimeters of the small intestine (ileal resection) can also result in a higher incidence of gallstones.
IBD Treatments and Gallstone Risk
Certain medications used to treat IBD can affect the liver and increase the risk of gallstone formation. Azathioprine, an immunosuppressant, can cause cholestasis, which reduces or stops bile flow. Sulfasalazine, used for inflammation in ulcerative colitis and Crohn’s disease, can potentially block the bile duct or normal bile flow.
Managing Gallstones With IBD
Surgical Treatments
Surgical removal of the gallbladder (cholecystectomy) is the typical treatment when gallstones create chronic or acute health issues alongside IBD. However, recent studies suggest it may complicate IBD management in the long run.
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Nonsurgical Treatments
When surgery is not an option, gallstones can be managed in other ways. Oral dissolution therapy, which involves taking medicine containing bile acids by mouth, can dissolve gallstones over months or years. Extracorporeal shock wave lithotripsy, a noninvasive treatment, uses shock waves to dissolve gallstones when the gallbladder is functional and the stones are not large.
Diet and Exercise
Diet and exercise can help manage gallstones in people with IBD, similar to those without IBD. A diet rich in plants, whole grains, and healthy fats, combined with exercise, reduces cholesterol and the risk of developing gallstones. Weight loss, when recommended, should be gradual, as rapid weight loss can lead to gallstone formation.
Home Management Tips
Individuals with IBD and gallstones have shared several home management tips:
- Eat smaller meals, reduce greasy food, and limit dairy intake.
- Drink plenty of fluids to avoid dehydration, which can exacerbate gallstone symptoms.
- Monitor food intake, avoid gluten, and eat mostly home-cooked meals.
- Use a heating pad for pain relief.
Managing IBD is crucial for mitigating complications like gallstones, improving quality of life, and promoting overall well-being.
Dietary Recommendations for Gallstone Management
Following gallbladder removal, the body may require adjustments to effectively digest food due to the continuous flow of bile into the small intestine. While there isn't a one-size-fits-all diet, certain foods should be limited or avoided, while others should be emphasized.
Foods to Limit or Avoid
- Fatty Meats: Processed or high-fat meats like steak, beef, pork, bacon, lunch meats, sausage, and lamb.
- Dairy Products: Milk, full-fat yogurt, full-fat cheese, butter, lard, sour cream, ice cream, and whipped cream. Opt for fat-free or low-fat alternatives, or non-dairy versions like almond milk.
- Highly Processed Foods: Pie, cake, cookies, cinnamon rolls, sugary cereals, white bread, and foods cooked in vegetable or partially hydrogenated oils.
Foods to Include
- High-Fiber Foods: Beans, lentils, peas, potatoes with skin, oats, barley, whole-grain bread, pasta, rice, cereal, raw nuts, raw seeds, and sprouted grains.
- Nutrient-Dense Fruits and Vegetables: Legumes, cauliflower, cabbage, Brussels sprouts, broccoli, spinach, kale, tomatoes, citrus fruits, avocados, blueberries, blackberries, and raspberries.
- Lean Meats or Meat Alternatives: Chicken breast, turkey, salmon, trout, herring, white fish, legumes, and tofu.
- Healthy Fats and Low-Fat, Fat-Free Foods: Avocado, olive, or coconut oil (in moderation), low-fat mayonnaise, milk, yogurt, sour cream, and ice cream.
Additional Tips
- Introduce Solid Foods Gradually: After surgery, slowly reintroduce solid foods to prevent digestive issues.
- Eat Small, Frequent Meals: Split meals into five to six small portions throughout the day to avoid gas and bloating.
- Limit Fat Intake: Aim for no more than 3 grams of fat per meal.
- Substitute Ingredients: Use applesauce instead of butter in baking or flax seeds and water as an egg substitute.
- Consider a Vegetarian Diet: Meats and dairy can be harder to digest without a gallbladder.
- Stay Active: Regular exercise and maintaining a healthy weight can aid digestion.
Additional Home Remedies
- Lemon Juice: The juice of one lemon may help ease symptoms.
- Herbal Tea: Steep 1 teaspoon (4 g) of dried herb in 1 cup (240 ml) of boiling water for 5 to 10 minutes. Globe artichoke may support gallbladder and liver health.
- Castor Oil Pack: Apply castor oil to the abdomen with a soft cloth, plastic wrap, and a hot water bottle or heating pad.
Medical Options
- Over-the-Counter Pain Relievers: Ibuprofen or acetaminophen may help with mild symptoms.
- Ursodiol: This oral bile acid can dissolve cholesterol-based gallstones.
- Shock Wave Therapy: Recommended for individuals with fewer than three stones.
- Cholecystectomy: Surgical removal of the gallbladder.
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