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Gallbladder stones

Gallbladder stones

Also known as Gall stones, Gallstone disease, Cholelithiasis and Cholecystolithiasis

Overview

A gallbladder stone or cholelithiasis is a health condition in which pieces of solid stone-like objects develop in the gallbladder or bile duct. These gallstones are usually made up of cholesterol or bilirubin, and may trigger a sudden, intense pain in the abdomen. For some individuals, it may either develop as a single large gallstone, while for others, it may develop several small gallstones.

The primary cause of gallbladder stones is not clearly understood. However, numerous factors increase the risk of developing gallstones; which includes chemical imbalance of bile in the gallbladder, excessive secretion of cholesterol in the liver, post organ transplant adverse effects, and/or certain medications. 

People who do not show any symptoms, usually don’t need any treatment. The treatment for gallbladder stones largely depends on the size and location of the gallstones. The common treatment involves dietary modification, medications, non-invasive ultrasound therapy (lithotripsy), and surgery.

Key Facts

Usually seen in
  • Adults above 30 years of age
Gender affected
  • Both men and women but more common in women
Body part(s) involved
  • Gallbladder
Prevalence
Mimicking Conditions
  • Stomach flu
  • Gastroenteritis 
  • Mirizzi syndrome 
  • Appendicitis
  • Ulcers 
  • Pancreatitis
  • Gastroesophageal reflux disease
  • Bile duct strictures
  • Bile duct tumors
  • Cholangiocarcinoma
  • Gall bladder cancer
  • Peptic ulcer disease
  • Pancreatic cancer
Necessary health tests/imaging
Treatment
  • Medications: Ursodeoxycholic acid & Chenodiol
  • Surgical treatments: Open cholecystectomy, Laparoscopic surgery, & Endoscopic gallbladder stenting
Specialists to consult
  • Gastroenterologist
  • General physician
  • General surgeon
  • Gastrointestinal surgeon

Symptoms Of Gallbladder Stones


Gallbladder stones symptoms differ from person to person, depending on the size and location of gallstones. The most prominent and visible gallbladder stones symptoms are sudden intensifying abdominal pain and other related digestive problems. For most people, the gall stones may remain silent and do not show any signs and symptoms. These types of silent gallstones usually do not pose any major risks of health concerns. However, if the gallstones block or get into the bile duct, they may cause other health complications. So it is always advised to consult a physician immediately for an early diagnosis and treatment.

Some of the common signs and symptoms of gallbladder stones include:

1. Sudden intensifying pain in the stomach

  • Sudden pain in the stomach is the most common symptom of gallbladder stone. The pain usually occurs at the upper right portion of the abdomen and may radiate to other regions. 

  • Increased pressure within the gallbladder or a block in the bile duct due to gallstones may cause pain in the abdomen.

  • This pain can last for around 20 minutes to several hours.

2. Flatulence

  • Some people with gallstones may develop flatulence. 

  • An increased amount of gas secretion or gas buildup in the digestive system due to underlying health conditions such as gallbladder stones can also trigger flatulence.

3. Nausea and vomiting

  • Another common symptom of gallbladder stones is nausea and vomiting. Increased pressure in the gallbladder caused by gallstones may increase the fluid imbalance in the stomach, which in turn may cause nausea and vomiting. 

Other gallbladder symptoms include:

  • Pale or yellowish skin

  • Loss of appetite

  • Abdominal bloating

  • Chest pain

  • Radiating pain in the right shoulder

  • Fever

  • Clay-colour stools

The warning symptoms that require urgent medical care include:

  • Severe or radiating abdominal pain

  • Yellowing of skin or whites of the eye

  • Stomach bloating

Most of the above-mentioned symptoms of gallbladder stones may resemble other gastrointestinal problems, such as ulcer, appendicitis, or pancreatitis. So early recognition and treatment of gall bladder stones are crucial to reducing the risks associated with it.

Kidney stones are not the same as gallstones. Here’s everything you need to know about kidney stones.

Causes Of Gallbladder Stones


The exact causes of gallbladder stones are not clearly understood. However, several factors are believed to contribute to the development of gallstones. Some possible causes of gallbladder stones include,


1. Imbalance of bilirubin in the bile

Elevated levels of bilirubin, a pigment secreted by the liver, may cause the accumulation of excess bilirubin in the body tissue. This, in turn, may contribute to the formation of gallstones.


2. Excessive secretion of cholesterol

Gallbladder stones develop when the liver secretes excessive cholesterol and results in the formation of cholesterol crystals, which develop into gallstones.


3. Improper emptying of the gallbladder

Improper emptying of the gallbladder, overtime may lead to the formation of mucus-like gallbladder sludge. This, in turn, may eventually develop into gallstones.


4. Insufficient bile salt concentration

Insufficient or imbalance in bile salt concentration correlates with an increased risk of developing gallbladder stones.


5. Diet and lifestyle

Certain lifestyle factors and improper dietary practices may also lead to the formation of stones in the gallbladder. These include:

  • Regular eating of highly processed and fried food items

  • Alcohol consumption

  • Stress

  • Obesity

  • Inactive or sedentary lifestyle

Did you know?
Lifestyle factors such as drinking too much of carbonated beverages, not drinking enough water and smoking can have a significant impact on your kidneys. Here’s more about the everyday habits that can harm the kidneys.
Did you know?

Risk Factors For Gallbladder Stones


Gallstones develop because of the imbalance in the chemical composition of the bile inside the gallbladder. The accumulation of high levels of cholesterol in the bile over time may form small crystals (gallstones), causing pain in the abdomen.

Some of the most common risk factors associated with gall bladder stones are listed below:

  • Smoking

  • Men older than the age of 60

  • Sedentary lifestyle

  • Pregnancy

  • Oral contraceptives 

  • Rapid weight loss

  • Liver disease 

  • Diabetes

  • Obesity

  • Metabolic disorders such as hyperparathyroidism (excessive secretion of thyroid hormone),.

  • Individuals with a family or medical history of gallstones

  • Eating low-fiber  diet

  • Taking certain medications that have anticholinergic effects 

  • Crohn disease, ileal resection, or other diseases of the ileum decrease bile salt reabsorption and increase the risk of gallstone formation.

  • Other illnesses or states that predispose to gallstone formation include burns, use of total parenteral nutrition, paralysis, ICU care, and major trauma.

Types Of Gallstones


The composition of gallstones is affected by age, diet and ethnicity. On the basis of their composition, gallstones can be divided into the following types: cholesterol stones, pigment stones, and mixed stones. An ideal classification system is yet to be defined.

Cholesterol stones

Cholesterol stones vary from light yellow to dark green or brown or chalk white and are oval, usually solitary, between 2 and 3 cm long, each often having a tiny, dark, central spot. To be classified as such, they must be at least 80% cholesterol by weight (or 70%, according to the Japanese–classification system). Between 35% and 90% of stones are cholesterol stones.


Pigment stones

Bilirubin ("pigment", "black pigment") stones are small, dark (often appearing black), and usually numerous. They are composed primarily of bilirubin (insoluble bilirubin pigment polymer) and calcium (calcium phosphate) salts that are found in bile. They contain less than 20% of cholesterol (or 30%, according to the Japanese-classification system). Between 2% and 30% of stones are bilirubin stones.


Mixed stones

Mixed (brown pigment stones) typically contain 20–80% cholesterol (or 30–70%, according to the Japanese- classification system). Other common constituents are calcium carbonate, palmitate phosphate, bilirubin and other bile pigments (calcium bilirubinate, calcium palmitate and calcium stearate). Because of their calcium content, they are often radiographically visible. They typically arise secondary to infection of the biliary tract which results in the release of β-glucuronidase (by injured hepatocytes and bacteria) which hydrolyzes bilirubin glucuronides and increases the amount of unconjugated bilirubin in bile. Between 4% and 20% of stones are mixed.

Gallstones can vary in size and shape from as small as a grain of sand to as large as a golf ball. The gallbladder may contain a single large stone or many smaller ones. Pseudoliths, sometimes referred to as sludge, are thick secretions that may be present within the gallbladder, either alone or in conjunction with fully formed gallstones.

Practicing  Dhanurasana Yoga Asana may help manage gallbladder stones better.

Have you ever thought that practicing a specific type of yoga may help you manage gallstones? According to a study, ayurvedic integrated yoga may help improve gastrointestinal mobility, reduce pain, abdomen bloating and provide relief from the signs and symptoms of gallbladder stones. Regular practicing of dhanurasana yoga or bow pose may also improve the normal functioning of the digestive system as it involves stretching of the spine. However, this pose is not usually recommended for severe gall bladder stone cases.  

Diagnosis Of Gallbladder Stones


If you are experiencing any symptoms of gallbladder stones, such as intense abdominal pain, extreme fatigue, flatulence, or stomach bloating, it is wise to consult a gastroenterologist or primary care physician. Early diagnosis and prompt treatment for gallstones reduce the risks associated with their own.

If your symptoms are mild, your physician might not recommend any tests. However, if your symptoms fail to show any improvement post-treatment or if you experience symptoms such as nausea or bloody stools, then your physician might recommend further investigation. The tests include:

Physical examination of the abdomen

If you experience any symptoms, your physician might perform a physical examination of your abdomen. Assessment of your abdomen may provide critical information about the internal organs. Some of the common physical examination for gallstones involves,

  • Evaluation of your physical appearances, such as yellow discolouration of skin and sclera (white layer of the eye).

  • Checking your vital signs such as blood pressure, body temperature, heart rhythm, and other signs of gallstones in your body

  • Examination of your abdomen for tenderness and distensions.

Abdominal ultrasound

Ultrasound, a non-invasive imaging procedure, is commonly used to diagnose the signs of gallstones. This test involves the use of high-frequency ultrasounds to visualize the organs and structures within the abdomen.


Endoscopic ultrasound

Endoscopic ultrasound (EUS) is also an accurate and relatively noninvasive technique to identify stones in the distal common bile duct. Sensitivity and specificity of CBD stone detection are reported in range of 85%-100%.


Complete blood count (CBC)

 The blood test may help reveal the cause of gastrointestinal obstruction. The elevated levels of bilirubin and cholesterol in the blood test may also help detect infection, pancreatitis, and other related abnormalities in the gallbladder. 


Magnetic resonance imaging (MRI)

An MRI scan of the abdomen can help detect the stones in the gallbladder. This test involves the use of strong magnetic fields and radio waves to create images of the internal organs. It is usually an outpatient procedure. So, you can go home the same day as the test.


Cholangiogram

Cholangiogram, also known as DISIDA (diisopropyl iminodiacetic acid) scan or gallbladder radionuclide scan, uses radioactive dye and a special scanning probe to detect small stones that may be missed on other imaging techniques. This scanning method is commonly used to detect and locate blocks in the bile.


Computed tomography (CT) abdomen scan

During this procedure, your doctor uses a special x-ray probe and a computer to create a cross-sectional image of the gallbladder. These images may help physicians spot ruptures (tears in the gallbladder wall) and infections in the gallbladder.

Other imaging tests include:

  • Abdominal X-ray

  • Oral cholecystography

  • Hepatobiliary iminodiacetic acid (HIDA) scan

  • Endoscopic retrograde cholangiopancreatography (ERCP)

To get the right diagnosis, it is important to consult the right doctor. Consult India’s best doctors online. 

Celebs affected

Manoj Kumar
Veteran Bollywood actor Manoj Kumar underwent gall bladder surgery in the year 2013.
Bharti Singh
Bharti Singh, an Indian comedian and television personality, was admitted to the hospital after complaining of stomach ache. She was diagnosed with gallstones.
Jack Black
The famous American actor, comedian, musician, and songwriter was also diagnosed with gallbladder stones. He underwent gallbladder removal surgery very early in his career.
Dalai Lama
The highest spiritual leader of Tibet, Dalai Lama, underwent surgery for the removal of gallbladder stones in the year 2008.

Prevention Of Gallbladder Stones


Although there are no definite steps to prevent gallbladder stones completely, some of the following preventive measures may help you manage the condition and reduce its implications.


1. Consume balanced diet

The food we eat has a huge impact on the health of the gallbladder. A 2020 study on the association of diet with symptomatic gallstones has reported that high consumption of high saturated fats increases the risk of gallstones. Hence, eating a healthy diet packed with all vital nutrients is crucial for preventing gallstone formation. 


2. Maintain healthy body weight

Being obese or overweight puts you at a higher risk of developing a gallbladder stone. Consult a nutritionist or a doctor who may help you chart out a proper diet plan to decrease the frequency of disease.


3. Don't skip your meal

Skipping your meal on a regular basis can cause adverse effects on health. Especially for people with gallbladder diseases, skipping meals may cause stress buildup in the bladder, which may lead to serious health complications. In general, it is advised to stick to mealtimes every day.


4. Be active

A sedentary lifestyle or being physically inactive can lead to the development of gallstones and many other health complications. Therefore, you should incorporate moderate exercises like jogging, stretching, and yoga to reduce your risk of gallstone.


5. Try to lose weight gradually

Rapid weight loss may trigger cholesterol secretion in the body. Especially for an obese patient who has undergone bariatric surgery (gastric bypass to lose weight), the sudden weight loss may increase the risk of developing gallstones. Thus, it's important to lose weight in a healthy, safe and gradual manner. 

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6. Take preventive medication if necessary

Gallbladder stones have a multifactorial etiology, and it shares similar symptoms with other related gastrointestinal disorders. However,  if the symptoms are recognized as soon as possible, early interventions can reduce the risk of complications.

Specialist To Visit


The signs of gallbladder stones often resemble those caused by other gastrointestinal conditions. In addition to that, some gallstones do not show any signs and remain silent. In such cases, the symptoms of gallbladder stones can rapidly get worse or lead to serious health complications.

Early diagnosis of gallbladder stones helps prevent complications and increases the outcomes of surgery.  So if you are bothered about symptoms or experiencing any warning signs of gallbladder stones, it is always better to seek immediate professional help to eliminate the progression of the gallstones.

Specialists that can help manage gallbladder stones include:

  • Gastroenterologist

  • General physician

  • General surgeon

  • Gastrointestinal surgeon

If you or anyone in your family are experoeicng any symptoms of gall bladder stones, seek medical help immediately. 


Treatment Of Gallbladder Stones


People who have silent gall bladder stones (asymptomatic gallstones) show mild symptoms and may not require any treatment. However, for people with gallstone complications and having intense pain in the abdomen, the following treatments may be required:


Nonsurgical treatments

Medications
The medications used to treat the gallbladder either work by breaking the cholesterol accumulation in the stomach acids or decreasing the cholesterol secretion in the bile. The most commonly used medicines for gallbladder stones include:

Ursodeoxycholic acid: Ursodeoxycholic acid or ursodiol is a naturally-occurring bile acid effective in the prevention of gallstones. It works by dissolving the excess cholesterol or gall stone crystals in the gut.

This class of medications is approved by the FDA for the treatment of gallstones. However, it may require a longer time to work. So the use of these medications is only considered for mild and less serious cases.

Chenodiol: Chenodiol or Chenodeoxycholic acid is also a naturally occurring bile acid used to treat gallstones. It works by preventing the secretion of excess cholesterol in the liver that develops into gallstones.

However, the use of this medication does not guarantee immediate recovery or results. It is commonly used by people who cannot undergo gallbladder surgery.

Other non-FDA approved medications to treat small gallbladder stones include::

  • Actigall

  • Reltone

Extracorporeal shock wave lithotripsy

Extracorporeal Shock Wave Lithotripsy is a non-invasive procedure that uses pressured waves to break gallstones externally. However, this technique involves the use of high-tech equipment and is rarely used along with other treatment methods.


Surgical treatments

Open cholecystectomy: One of the effective methods to cure gallstones is surgery. Surgical treatment usually involves removal of the gallbladder to avoid recurrence of gallstones.

However, like other surgery, gallbladder surgery also comes with its own risk of complications.The most common complication is an internal bleeding injury to the bile ducts, infection. For which you may need one or more additional operations to repair the bile ducts.

Laparoscopic surgery (cholecystectomy): Laparoscopic surgery, often known as keyhole surgery, is a highly effective technique widely used to treat gallbladder stones. It involves the use of a special probe to access the internal organs.

The main advantage of laparoscopic surgery over traditional open surgery is that it requires minimal opening and a small incision to perform surgery. This, in turn, eliminates the major risks of open surgery such as infection, internal bleeding, or delayed recovery.

Endoscopic gallbladder stenting: Endoscopic gallbladder stenting is effective for elderly patients with gallbladder diseases who are poor surgical candidates. This procedure uses stents (metal or plastic tube inserts) to keep the bile duct narrowed by gallstones open.

Gallbladder stenting may also help resolve the symptoms caused by gallstones.

Did you know?
Breaking a large meal into small meals has numerous health benefits ranging from stabilizing blood sugar levels to boosting the overall body's metabolism. According to the article published in the Nutrition Journal, the frequency and timing of the diet play an important part in gallstone formation. Following healthy eating habits, fasting, regular meal frequency, and timing may help prevent the occurrence of gallbladder stones.
Did you know?

Home-care For Gallbladder Stones


Diet plays a crucial role in the management and treatment of gallbladder stones. Here are some dos and don'ts you need to follow to help your body manage gallstones symptoms:


Dos

  • Consume food rich in fiber, such as vegetables and fruits.

  • Don’t miss out on micronutrients, consume a well-rounded diet such as legumes and whole grains.

  • Keep your blood pressure under control.

  • Make sure to break your large meal into small meals—for example, instead of eating one large meal, break it into 3 small meals.

  • Practice low intense stretch exercises to help proper digestion.

  • Make sure to chew your food slowly and properly.

  • Stay hydrated, drink lots of water.

  • Herbs such as Saindhava lavanam and peppermint may help you manage the signs of gallstones.

Don'ts

  • Eat too many fried, spicy, or ready-made packed food items like pasta, noodles, polished rice, and sugar.

  • Drink aerated cool drinks such as soda and ice beverages, excessively

  • Smoke or consume alcohol

  • Perform high intense physical activities like weight lifting, sprinting, or boxing

  • Eat high fat or calcium-rich food

  • Self-medicate

Complications Of Gallbladder Stones


Usually, asymptomatic gallstones do not cause any complications. However, if the symptoms are left untreated, it can lead to severe complications. According to the Nigerian Journal of Surgery, the medical complications associated with gallbladder stones are as follows:

  • Inflammation of the gallbladder can lead to a more serious medical condition called cholecystitis

  • Blockage of bile duct resulting in bile infection or jaundice

  • Gallbladder cancer

  • Blockage in the pancreatic duct leading to pancreatitis, a serious medical condition where the pancreas get inflamed due to the presence of blockage

  • Small bowel obstruction or gallstone ileus, a rare but serious complication where the intestine losses its ability to contraction 

  • Mirizzi's syndrome, a condition where the bile stone becomes impacted with the neck of the gallbladder

  • Internal bleeding or gastrointestinal distress

Alternative Therapies For Gallbladder Stones


Home remedies for Gallstones

 

Here are a few quick home remedies to control and get relief from gallstones.

1. Turmeric (haldi)

Turmeric has potent anti-inflammatory properties. The active compound of turmeric curcumin is scientifically proven to have health benefits.

Tip: Take warm water or milk infused with 3 g of turmeric after meals. This drink can help with gut inflammation and gallstone problems

2. Aloe vera

Aloe vera leaves are enriched with antioxidants and vitamins.

Tip: 

  1. Extract the gel from aloe vera leaves.

  2. Boil a cup of leaf extract in water.

  3. Add salt to taste.

  4. Drink this concoction two times a day. This drink can help fight acid reflux, gas trouble, and other symptoms of gallstones.

3. Gokshura

Gokshura is loaded with a variety of Saponins that slow down the progression of the galls stones.

Tip: Taking Gokshura with Ashwagandha and Shilajit as Gokshura suranum or simply as a powdered form can help detoxify the gallbladder.

4. Black pepper (kali mirch)

Black pepper neutralizes the excess acid and helps regulate the bile secretion in the liver. It also contains numerous medicinal compounds such as piperine which improves the proper functioning of the gallbladder.

Tip: Drink a glass of black pepper with warm water every day after meals if you are prone to frequent stomach distress.

5. Onion seeds (kalonji)

Kalonji contains antioxidant thymoquinone, which aids in reducing abdomen pain, infection, and gallstones. 

Tip: 

  1. Add a teaspoon of Kalonji oil to around 2-3 glasses of water and boil. 

  2. Strain it and drink this water at regular intervals post meals/breakfast for quick pain relief.

6. Cucumber beet juice

People with gallstones may have increased bile or cholesterol secretion and suffer from indigestion problems. Cucumber beet juice serves as an excellent source of remedy for this.

Tip: 

  1. Mix equal volume of cucumber, beetroot, carrot.

  2. Dilute it by adding glasses of water.

  3. Drink this water at regular intervals post meals/breakfast to replenish your body.

7. Dandelion tea

Dandelion tea has antibacterial and antimicrobial properties that help fight gastric infection. It also has numerous positive benefits on your digestive system. 

Tip: Add 10g of dry Dandelion leaves to around 2-3 glasses of water and boil. Strain it and drink. This boiled water can also be taken as a natural substitute for coffee.

8. Pear

Pear is loaded with antioxidants and antimicrobial properties that help fight the symptoms of gallbladder stones. 

Tip: Make fresh pear juice. Strain it and drink. Drinking pear juice at regular intervals (weekly once) may reduce the formation of bile stones and cholesterol deposits.


Yoga for gallbladder stones

Some common yoga poses for peptic ulcers include the following:

  • Bhujangasana (Cobra Pose)

  • Dhanurasana (Bow Pose)

  • Paschimottanasana (Seated forward bend)

  • Sarvangasana (Shoulderstand)

  • Shalabhasana (Locust Pose)

Did you know?
Drinking lemon juice regularly keeps you hydrated throughout the day. In addition to that, lemon juice has numerous health benefits, such as preventing gallstone formation and aiding in digestion and regulation of cholesterol secretion in the liver. According to an article published in the Scientific report Journal, lemon juice is loaded with nutrients, including vitamin C, B-complex vitamins, calcium, iron, magnesium, potassium, fiber, and has anti-aging properties.
Did you know?

Living With Gallbladder Stones


If you have been diagnosed with gallbladder stones, your physician will provide the right treatment plan. However, making significant diet and lifestyle changes along with medication are also crucial. With adequate treatment and care, gallstones heal over time. However, you need to follow a high fiber and low salt diet to reduce the chances of relapse.

In addition, here are a few tips that can help you manage and prevent gallbladder stones.

  • Stop smoking

  • Moderate alcohol consumption

  • Maintain healthy BMI (Body Mass Index) limit

  • Stay hydrated 

  • Avoid eating unhealthy fats

  • Don't skip meals

  • Take all the medications as recommended by your doctor.

  • Seek professional help if need

  • Participate in support groups

Frequently Asked Questions

References

  1. Everhart JE, Ruhl CE. Burden of digestive diseases in the United States. Part III: liver, biliary tract, and pancreas. Gastroenterology 2009; 136: 1134-1144.External Link
  2. Everhart JE, Khare M, Hill M, Maurer KR. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 1999; 117: 632-639.External Link
  3. Angelico F, Del-Ben M, Barbato A et al. Ten-year incidence and natural history of gallstone disease in a rural population of women in central Italy. GREPCO. Ital J Gastroenterol 1997; 29: 249-254.External Link
  4. Acalovschi M, Dumitrascu D, Clauser I, Ban A. Comparative prevalence of gallstone disease at 100-year interval in a large Romanian town. Dig Dis Sci 1987; 32: 354-357.External Link
  5. Aerts R, Penninckx F. The burden of GD in Europe. Aliment Pharmacol Ther 2003; 18/suppl.3: 49-53. External Link
  6. Stinton LM, Shaffer EA. Epidemiology of gallbladder disease: cholelithiasis and cancer. Gut and Liver 2012; 6: 172-187.External Link
  7. Tazuma S. Epidemiology, pathogenesis, and classification of biliary stones (common bile duct and intrahepatic). Best Pract Res Clin Gastroenterol 2006; 20:1075-1083.External Link
  8. Diehl AK, Rosenthal M, Hazuda H et al. Socioeconomic status and the prevalence of clinical gallbladder disease. J Chron Dis 1985; 38:1019-1026.External Link
  9. Freeman J, Boomer L, Fursevich D, Felix A. Ethnicity and insurance status affect health disparities in gallstone patients. J Surg Res 2012; 175: 1-5.External Link
  10. Russo MW, Wei JT, Thiny MT et al. Digestive and liver diseases statistics, 2004. Gastroenterology 2004; 126: 1448-1453.External Link
  11. National Institutes of Health Consensus Development Conference Statement on gallstones and laparoscopic cholecystectomy. Am J Surg 1993; 165: 390-398.External Link
  12. Lammert F, Neubrand MW, Bittner R et al. S3-guidelines for diagnosis and treatment of gallstones. German Society for Digestive and Metabolic Diseases and German Society for Surgery of the Alimentary Tract. Z Gastroenterol 2007; 45: 971-1001.External Link
  13. Nakeeb A, Comuzzle AG, Martin L et al. Gallstones: genetics versus environment. Ann Surg 2002; 235: 842-849.External Link
  14. Katsika D, Grjibovski A, Einarsson C et al. Genetic and environmental influences on symptomatic GD: a Swedish study of 43,141 twin pairs. Hepatology 2005; 42:1138-1143.External Link
  15. Buch S, Schafmayer C, Volzke H, et al. A genome-wide association scan identifies the hepatic cholesterol transporter ABCG8 as a susceptibility factor for human gallstone disease. Nat Genet 2007; 39,:995-999.External Link
  16. Grünhage F, Acalovschi M, Tirziu S et al. Increased gallstone risk in humans conferred by a common variant of hepatic ATP-binding cassette transporter for cholesterol. Hepatology 2007; 46: 793-801.External Link
  17. Finucane MM, Stevens GA, Cowan MJ, et al. National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 countryyears and 9·1 million participants. Lancet 2011; 377(9765): 557-67.External Link
  18. Centers for Disease Control and Prevention (CDC). Vital signs: state-specific obesity prevalence among adults - the United States, 2009. MMWR Morb Mortal Wkly Rep 2010; 59: 951-955. External Link
  19. Danaei G, Finucane MM, Lu Y, et al. National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants. Lancet 2011; 378(9785):31-40. External Link
  20. Wild S, Roglic G, Green A et al. Global prevalence of diabetes. Estimates for the year 2000 and projections for 2030. Diabetes Care 2004; 27: 1047-1053. External Link
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