Gallstone Basics The gallbladder sits beneath the liver and stores bile (a key digestive juice).

. Gallstones are crystallized pieces of bile, which can range in size from microscopic to more than one inch. Almost 1 million Americans are diagnosed with gallstone disease each year. A variety of treatment options are available, with the most common being cholecystectomy. Alternatives to Cholecystectomy There are alternatives to surgery for both stones in the gallbladder and stones in the bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) can be used to find and remove stones in the bile duct, as described under Tests. When duct stones are seen, the doctor can widen the bile duct opening and pull the stones into the intestine. This is commonly performed shortly before or after laparoscopic gallbladder removal if a stone is suspected or identified in the bile duct. Stones may occasionally be identified in the common bile duct long after the gallbladder has been removed. Gallbladder stones can sometimes be dissolved by a chemical (ursodiol or chenodiol), which is available in pill form. This medicine thins the bile and allows stones to dissolve. Unfortunately, only small stones composed of cholesterol dissolve rapidly and completely and its use is therefore limited to patients with the right size and type of stones. Gallstones Gallstone disease is a common medical problem, affecting 10 percent to 15 percent of the population of the U.S., or well over 25 million people. Nearly 1 million new cases of gallstone disease are diagnosed every year in this country. Approximately one-quarter of these require treatment, with a cost to society of several billion dollars annually. In recent years, important advances have been made in the understanding of gallstone disease and in the development of new treatments. The Gallbladder The gallbladder is a sac, about the size and shape of a pear, which lies on the undersurface of the liver in the upper right-hand portion of the abdominal cavity. It is connected to the liver and the intestine by a series of small tubes, or ducts. The primary job of the gallbladder is to store bile, which is produced and secreted continuously by the liver, until the bile is needed to aid in digestion. After a meal, the gallbladder contracts and bile flows into the intestine. When digestion of the meal is over, the gallbladder relaxes and once again begins to store bile. Bile is a brown liquid which contains bile salts, cholesterol, bilirubin and lecithin. About 3 cups of bile are produced by the liver every day. Some substances in bile, including bile salts and lecithin, act like detergents to break up fat so that it can be easily digested. Others, like bilirubin, are waste products. Bilirubin is a dark brown substance which gives a brown color to bile and stool. Gallstones & How They Form Gallstones are pieces of hard solid matter in the gallbladder. They form when the components of bile including cholesterol and bilirubin precipitate out of solution and form crystals, much as sugar may collect in the bottom of a syrup jar. In the U.S., almost 80 percent of patients with gallstones have cholesterol stones. Gallstones may be as small as a grain of sand or as large as a golf ball, and the gallbladder may contain anywhere from one stone to hundreds. Sometimes the gallbladder contains only crystals and stones too small to see with the naked eye. This condition is called biliary sludge.

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It is not entirely known why some people develop gallstones and others dont; however, certain factors are known to increase the likelihood of developing gallstones: An increased amount of cholesterol or bilirubin in bile Poor contraction of the gallbladder muscle with incomplete emptying of the gallbladder Obesity Sedentary lifestyle Female gender Age over forty years old Diabetes Liver disease Family history of gallstones Pigment (bilirubin) gallstones are found most often in: Patients with severe liver disease. Patients with some blood disorders such as sickle cell anemia and leukemia. Cholesterol gallstones are found most often in: Women over 20 years of age, especially pregnant women, and men over 60 years of age. Overweight men and women. People on crash diets who lose a lot of weight quickly. Patients who use certain medications including birth control pills and cholesterol lowering agents. Native Americans. Hispanics of Mexican origin. Gallstone Symptoms Many people with gallstones have no symptoms. Often the gallstones are found when a test is performed to evaluate some other problem. So-called silent gallstones are likely to remain silent, and no treatment is recommended. The most typical symptom of gallstone disease is severe steady pain in the upper abdomen or right side. The pain may last for as little as 15 minutes or as long as several hours. The pain may also be felt between the shoulder blades or in the right shoulder. Sometimes patients also have vomiting or sweating. Attacks of gallstone pain may be separated by weeks, months or even years. Gallstone Complications It is thought that gallstone pain results from blockage of the gallbladder duct (cystic duct) by a stone. When the blockage is prolonged (greater than several hours), the gallbladder may become inflamed. This condition, called acute cholecystitis, may lead to fever, prolonged pain and eventually infection of the gallbladder. Hospitalization is usually necessary for observation, for treatment with antibiotics and pain medications, and frequently for surgery. More serious complications may occur when a gallstone passes out of the gallbladder duct and into the main bile duct. If the stone lodges in the main bile duct, it can lead to a serious bile duct infection. If it passes down the bile duct, it can cause an inflammation of the pancreas, which has a common drainage channel with the bile duct. Either of these situations can be extremely dangerous. Stones in the bile duct usually cause pain, fever and jaundice (yellow discoloration of the eyes and skin) sometimes accompanied by itching. Tests Used to Diagnose Gallstones

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The most important parts of any diagnostic process are the patients description of symptoms and the doctors physical examination. When gallstones are suspected, routine liver blood tests are helpful since bile flow may be blocked and bile may back up into the liver. Abdominal ultrasound: Most commonly used to determine the presence of gallstones. A special instrument is used to bounce sound waves against hard objects like stones. Ultrasound is approximately 95 percent effective in diagnosing gallstones; however, it is not very accurate in determining if a stone has passed out of the gallbladder into the bile duct. o Cholescintigraphy, or HIDA scan: A radioactive tracer is injected into a vein, taken up by the liver and excreted, or eliminated, into the bile. This exam can help determine how well the gallbladder contracts in addition to giving information about whether stones are present within the cystic or common bile ducts. o CT scans: May detect gallstones; however, are less accurate than abdominal ultrasound. The most accurate tests to identify stones in the bile duct include: o Magnetic resonance imaging (MRI) scans. Endoscopic ultrasound or EUS (which utilizes a small ultrasound probe at the tip of an endoscope passed into the stomach). o Endoscopic retrograde cholangiopancreatography or ERCP (X-ray dye injected into the bile duct through an endoscope passed through the mouth). These tests may carry small risks. It is important to talk to your gastroenterologist about which test is most appropriate for you. o o Treatments for Gallstones When gallstones are not causing symptoms, treatment is usually unnecessary. Surgical removal of the gallbladder (cholecystectomy) is the most widely used therapy when symptoms have arisen from gallstones. Patients generally do well after surgery and have no difficulty with digesting food, even though the gallbladders function is to aid digestion. In laparoscopic cholecystectomy, the surgeon makes several incisions in the abdomen through which a tiny video camera and surgical instruments are passed. The video picture is viewed in the operating room on a TV screen, and the gallbladder can be removed by manipulating the surgical instruments. Because the abdominal muscles are not cut, there is less postoperative pain, quicker healing and better cosmetic results. The patient usually can go home from the hospital within a day and resume normal activities within a few days. Laparoscopic cholecystectomy has become common and is now used for more than 90 percent of all gallbladder removals in the U.S. However, it cannot be used in all cases. For instance, it may be difficult or dangerous to remove a severely inflamed gallbladder laparoscopically. It may also be more difficult to remove a stone from the bile duct laparoscopically, if one is found at surgery to have passed out of the gallbladder and into the duct. However, stones in the bile duct can frequently be removed with ERCP. Gallbladder surgery may be complicated by injury to the bile duct, leading either to leakage of bile or scarring and blockage of the duct. Mild cases can frequently be treated without surgery, but severe injury generally requires bile duct surgery. Bile duct injury is the most common complication of laparoscopic cholecystectomy

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Gallstones Gallstones are made from cholesterol and other things found in the bile. They can be smaller than a

grain of sand or as large as a golf ball. Most gallstones do not cause problems. But if they block a duct, they usually need treatment.

Gallstones develop when cholesterol and other substances in the bile form crystals that become hard stones in the gallbladder. The gallbladder is a small sac located just under the liver. Gallstones can form when too much cholesterol is in the bile or when the gallbladder does not empty properly. Cholesterol Cholesterol is an important fatlike substance (lipid) that is made in the liver and is necessary for the body to function. It also is found in foods made from animal products (meat and dairy products). Cells need cholesterol to function. However, excess cholesterol in the blood builds up in blood vessels and may lead to hardening of the arteries (atherosclerosis), heart disease, and stroke. People who have diabetes are at higher risk of developing atherosclerosis. There are two main forms of cholesterol: Low-density lipoprotein (LDL) is called "bad cholesterol." Most efforts to lower cholesterol are aimed at reducing levels of LDL. High-density lipoprotein (HDL) is called "good cholesterol." It can help remove excess cholesterol from the blood vessels. The cholesterol level can be checked with a blood test. If it is too high, lifestyle changes (such as diet changes and exercise) may help lower it. Some people may need medication to lower their cholesterol levels and reduce their risk of heart disease

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What causes gallstones? Gallstones form when cholesterol and other things found in bile make stones. They can also form if the gallbladder does not empty as it should. People who are overweight or who are trying to lose weight quickly are more likely to get gallstones. What are the symptoms? Most people who have gallstones do not have symptoms. If you have symptoms, you most likely will have mild pain in the pit of your stomach or in the upper right part of your belly. Pain may spread to your right upper back or shoulder blade area. Sometimes the pain is more severe. It may be steady, or it may come and go. Or it may get worse when you eat. See a picture of where pain may occur in the belly Abdominal pain .

Generalized pain occurs in two or more areas of the abdomen. Localized pain occurs in one area only or in one specific quadrant or region (such as epigastric, periumbilical, or pelvic). When gallstones keep blocking a bile duct , you may have pain with fever and chills, or your skin or the (pancreatitis). These symptoms may also be a

whites of your eyes may turn yellow. Call your doctor right away. Having stones in your bile duct increases your chance of having a swollen pancreas sign of an infected gallbladder. Call your doctor right away if you have sudden or bad pain in your belly or chest and you are not sure what is causing it. Symptoms of gallstones may feel like chest pain caused by a heart attack and other serious problems

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Pancreas

The pancreas is an organ in the upper belly, behind the stomach and close to the spine. It makes digestive enzymes that your body uses to break down and process food. The pancreas also makes insulin, the hormone that regulates sugar (glucose) in the blood. Pancreatitis Pancreatitis is an inflammation of the pancreas, which is an organ in the upper abdomen that makes insulin and digestive enzymes. Pancreatitis may cause sudden, severe abdominal pain. Pancreatitis is most commonly caused by excessive use of alcohol or by a blockage of the tube (duct) that leads from the pancreas to the beginning of the small intestine (duodenum), usually by a gallstone. Other causes include an infection, an injury, or certain medicines. It may develop suddenly (acute), or it may be a long-term, recurring (chronic) problem. Treatment in the hospital includes pain medicine and fluids given through a vein (IV) until the inflammation goes away. Nutrition is given through a tube to avoid stimulating the pancreas. Although most people recover fully from pancreatitis, complications such as bleeding, infection, or organ failure may develop.

How are gallstones diagnosed? You may go to the doctor because of pain in your belly. In this case, your doctor will ask you questions about when the pain started, where it is, and if it comes and goes or is always there. Your doctor may order imaging tests. These take pictures of the inside of your body. An ultrasound of the belly is the best test to find gallstones. This test does not hurt. Your ultrasound may not show gallstones. But if your doctor still thinks you have a problem with your gallbladder, he or she may order a gallbladder scan. In this test, a doctor injects dye into a vein in your arm. Then a machine takes X-rays as the dye moves through your liver, bile duct, gallbladder, and intestine

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Image tests Image tests provide pictures of bones, organs (such as the liver, pancreas, or intestines), tissues, and other structures (such as blood vessels) inside the body. These tests are used to help diagnose medical conditions. Image tests include: X-rays, which use a radiation beam to detect bone injuries or abnormal growths or changes in bone structure or size. Ultrasound, which uses reflected sound waves to produce an image. Ultrasound is most useful for looking at organs and structures that are either uniform and solid (like the liver) or that contain water (like the gallbladder). Mineralized structures (like bones) or air-filled organs (like the lungs) do not show up well. Echocardiography is a type of ultrasound that produces an image of the heart. It is used in heart conditions. Computed tomography (CT or CAT), which uses a series of X-ray pulses through the body to obtain information about almost any body organ, blood vessels, the abdominal cavity, bones, and the spinal canal. Magnetic resonance image (MRI), which uses a magnetic field and pulses of radio-wave energy to detect changes in the normal structure and characteristics of organs or tissues. An MRI can provide information that cannot be obtained from an X-ray, ultrasound, or CT scan. MRI is most effective at providing pictures of tissues that contain water, such as ligaments and muscles. An MRI is not as useful in looking at structures that do not contain water, such as bones. Nuclear medicine scans, which use a camera to take pictures of certain tissues in the body after a radioactive tracer (radionuclide or radioisotope) is put into the body. The radioactive tracer helps make the tissues visible on the scanning pictures. Each type of tissue that may be scanned (including bones, organs, glands, and blood vessels) uses a different radioactive compound as a tracer. Positron emission tomography (PET), which combines computed tomography and nuclear scanning. PET has been used primarily in heart and brain conditions and cancer. Ultrasound Ultrasound is a test that uses reflected sound waves to produce an image of organs and other structures in the body. It does not use X-rays or other types of possibly harmful radiation. For ultrasound testing, gel or oil is applied to the skin to help transmit the sound waves. A small, handheld instrument called a transducer is passed back and forth over the area of the body that is being examined. The transducer sends out high-pitched sound waves (above the range of human hearing) that are reflected back to the transducer. A computer analyzes the sound waves and converts them into a picture that is displayed on a TV screen. The picture produced by ultrasound is called a sonogram, echogram, or ultrasound scan. Pictures or videos of the ultrasound images may be made for a permanent record. Ultrasound is most useful for looking at organs and structures that are either uniform and solid (such as the liver) or fluid-filled (such as the gallbladder). Mineralized structures (such as bones) or air-filled organs (such as the lungs) do not show up well on a sonogram

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Most people have gallstones but do not know it because they do not have symptoms. Gallstones may be found by accident when you have tests for other health problems, or when a woman has an ultrasound during pregnancy. How are they treated? If you do not have symptoms, you probably do not need treatment. If your first gallstone attack causes mild pain, your doctor may tell you to take pain medicine and wait to see if the pain goes away. You may never have another attack. Waiting to see what happens usually will not cause problems. If you have a bad attack, or if you have a second attack, you may want to have your gallbladder removed. A second attack means you are more likely to have future attacks. Many people have their gallbladders removed, and the surgery usually goes well. Doctors most often use laparoscopic surgery. For this, your surgeon will make small cuts in your belly and remove your gallbladder. You will probably be able to go back to work or your normal routine in a week or two, but it may take longer for some people. Sometimes the surgeon will have to make a larger cut to remove the gallbladder. It will take longer for you to recover from this type of surgery. Do I need my gallbladder? Your body will work fine without a gallbladder. Bile will flow straight from the liver to the intestine. There may be small changes in how you digest food, but you probably will not notice them. Gallstones - Prevention There is no sure way to prevent gallstones. But you can reduce your risk of forming gallstones that can cause symptoms. Maintain a healthy weight Stay close to a healthy weight. Research shows that intentional weight loss (dieting, not weight loss from illness) followed by unintentional weight gain may increase your risk for forming gallstones, especially if you are a woman.3 If you need to lose weight, do so slowly and sensibly. When dieting, aim for a weight loss of only 1lb to 1.5lb per week. For more information, see the topic Healthy Weight. It is also important to avoid rapid weight loss and starvation diets. If you are on a rapid weight-loss diet, it is recommended that you be under a health professional's care. You may want to ask your health professional about taking medicines to help reduce your chances of developing gallstones while you are on such a diet. Eat regular, balanced meals Research shows that eating regular meals that contain some fat (which causes the gallbladder to empty) can help prevent gallstones. Eat plenty of whole grains and fiber, and have regular servings of food that

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contain calcium (found in green, leafy vegetables and milk products). Limit saturated (animal) fat and foods high in cholesterol.4 Exercise regularly Increased levels of physical exercise also may be an important way to reduce your risk of forming gallstones. One study has shown that women who exercised regularly decreased their risk of having to have the gallbladder removed. Exercising 2 to 3 hours per week reduced the women's risk by 20%.
5

In a large study of men, 2 to 3 hours of moderate running per week reduced by 20% the risk of forming gallstones that cause symptoms.6 Along with eating a low-fat diet, exercise is also an effective way to help you stay close to a healthy weight and lower your cholesterol and triglyceride levels. Deciding whether to take estrogen Some evidence shows that taking hormones such as estrogen after menopause or taking high-dose birth control pills may increase a woman's risk of forming gallstones that cause symptoms.1 If you are taking such hormones, talk with your health professional. Laparoscopic gallbladder surgery for gallstones Laparoscopic gallbladder surgery order to see clearly. The surgeon inserts a lighted scope attached to a video camera (laparoscope) into one incision near the belly button. The surgeon then uses a video monitor as a guide while inserting surgical instruments into the other incisions to remove your gallbladder. Before the surgeon removes the gallbladder, you may have a special X-ray procedure called intraoperative cholangiography, which shows the anatomy of the bile ducts. You will need general anesthesia for this surgery, which usually lasts 2 hours or less. After surgery, bile flows from the liver (where it is made) through the common bile duct and into the small intestine. Because the gallbladder has been removed, the body can no longer store bile between meals. In most people, this has little or no effect on digestion. In about 2 out of 10 laparoscopic gallbladder surgeries in the United States, the surgeon needs to switch to an open surgical method that requires a larger incision.1 Examples of problems that can require open rather than laparoscopic surgery include unexpected inflammation, scar tissue, injury, or bleeding. (cholecystectomy) removes the gallbladder and gallstones through

several small incisions in the abdomen. The surgeon inflates your abdomen with air or carbon dioxide in

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What To Expect After Surgery You may have gallbladder surgery as an outpatient, or you may stay 1 or 2 days in the hospital. After surgery you may have: Pain in your shoulder and belly that lasts 24 to 72 hours (from gas used to inflate the abdomen during surgery). It may last as long as a week. Widespread muscle aches from anesthesia. Diarrhea. Minor inflammation or drainage at the surgical wound sites. Loss of appetite and some nausea.

Most people can return to their normal activities within a week to 10 days. People who have laparoscopic gallbladder surgery are sore for about a week, but within 2 to 3 weeks they have much less discomfort than people who have open surgery. No special diets or other precautions are needed after surgery. Why It Is Done Laparoscopic gallbladder surgery is the best method of treating gallstones that cause symptoms, unless there is a reason that the surgery should not be done. Laparoscopic surgery is used most commonly when no factors are present that may complicate the surgery. Conditions that may require an open surgery instead of a laparoscopic surgery include: Severe inflammation or infection of the bile duct (cholangitis). Inflammation of the abdominal lining (peritonitis). High pressure in blood vessels in the liver. This is caused by cirrhosis of the liver (portal hypertension). Being in the third trimester of pregnancy. A major bleeding disorder or use of medicines to prevent blood clotting (blood thinners or anticoagulants). Scar tissue from previous abdominal surgeries. Scar tissue may make laparoscopic surgery more difficult. A severe lung disease, such as emphysema, because the way the abdomen is inflated with air for surgery may make it harder to breathe. Depending on the surgeon's experience and how severe your condition is, laparoscopic surgery also may not be an option if you have:

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Sudden (acute) inflammation or infection of the gallbladder (although laparoscopic surgery is being done more often in this situation).

Active inflammation or infection of the pancreas (pancreatitis). A minor bleeding disorder. Gallstones in the common bile duct. A separate procedure called endoscopic retrograde cholangiopancreatography that is done before or after the laparoscopic surgery can remove stones in the common bile duct.

How Well It Works

Excessive body weight.

Laparoscopic gallbladder surgery is safe and effective.1 Surgery gets rid of gallstones located in the gallbladder. It does not remove stones in the common bile duct. Gallstones can form in the common bile duct years after the gallbladder is removed, although this is rare. Risks The overall risk of laparoscopic gallbladder surgery is very low. The most serious possible complications include: Infection of an incision. Internal bleeding. Injury to the common bile duct. Injury to the small intestine by one of the instruments used during surgery. Risks of general anesthesia.

Other uncommon complications may include: Injury to the cystic duct, which carries bile from the gallbladder to the common bile duct. Gallstones that remain in the abdominal cavity. Bile that leaks into the abdominal cavity. Injury to abdominal blood vessels, such as the major blood vessel carrying blood from the heart to the liver (hepatic artery). This is rare. A gallstone being pushed into the common bile duct. The liver being cut.

More surgery may be needed to repair these complications.

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After gallbladder surgery, some people have ongoing abdominal symptoms, such as pain, bloating, gas, and diarrhea (postcholecystectomy syndrome). What To Think About Recovery is much faster and less painful after laparoscopic surgery than after traditional open surgery.
1, 2

The hospital stay after laparoscopic surgery is shorter than after open surgery. People generally go home the same day or within 1 day, compared with 2 to 4 days or longer for open surgery.

Recovery is faster after laparoscopic surgery. You will spend less time away from work and other activities after laparoscopic surgery (about a week to 10 days compared with 4 to 6 weeks).

Types of surgery to remove the gallbladder

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Gallstones Gallstones form in the gallbladder, a small organ located under the liver. The gallbladder aids in the digestive process by storing bile and secreting it into the small intestine when food enters. Bile is a fluid produced by the liver and is made up of several substances, including cholesterol, bilirubin, and bile salts. What Are Gallstones? Gallstones are pieces of solid material that form in the gallbladder. These stones develop because cholesterol and pigments in bile sometimes form hard particles. The two main types of gallstones are: Cholesterol stones (approximately 80% of gallstone cases): These are usually yellow-green in color. Pigment stones: These stones are smaller and darker and are made up of bilirubin.

What Causes Gallstones? Several factors may come together to create gallstones, including: genetics (others in your family have had gallstones) body weight decreased motility (movement) of the gallbladder diet

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Gallstones can form when there is an imbalance in the substances that make up bile. For instance, cholesterol stones may develop as a result of too much cholesterol in the bile. Another cause may be the inability of the gallbladder to empty properly. Pigment stones are more common in people with certain medical conditions, such as cirrhosis (a liver disease in which scar tissue replaces healthy liver tissue) or blood diseases such as sickle cell anemia. What Are the Risk Factors for Gallstones? Risk factors for getting gallstones include: Obesity. This is one of the biggest risk factors. Obesity can cause a rise in cholesterol, and can also keep the gallbladder from emptying completely. Estrogen. Women who are pregnant or who take birth control pills or hormone replacement therapy have higher levels of estrogen. This can cause a rise in cholesterol, as well as a reduction in gallbladder motility. Ethnic background. Certain ethnic groups, including Native Americans and Mexican-Americans, are more likely to develop gallstones. Gender and age. Gallstones are more common among women and among older people. Cholesterol drugs. Some cholesterol-lowering drugs increase the amount of cholesterol in bile, which may increase the chances of developing cholesterol stones. Diabetes. People with diabetes tend to have higher levels of triglycerides (a type of blood fat), which is a risk factor for gallstones. Rapid weight loss. If a person loses weight too quickly, his or her liver secretes extra cholesterol, which may lead to gallstones. Also, fasting may cause the gallbladder to contract less. What Are the Symptoms of Gallstones? Gallstones often don't cause symptoms. Those that don't are called "silent stones." A person usually learns he or she has gallstones while being examined for another illness. When symptoms do appear, they include the following: Pain in the upper abdomen and upper back. The pain may last a long time (several hours). Nausea

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Vomiting Other gastrointestinal problems, including bloating, indigestion, and gas

How Are Gallstones Diagnosed? If your doctor suspects you have gallstones, he or she will do a physical examination and may perform various other tests, including the following: Blood tests to check for signs of infection or obstruction and/or to rule out other conditions. Ultrasound: This procedure transmits high frequency sound waves through the body. The echoes are recorded and transformed into images of various parts of the body. An ultrasound can be used to identify gallstones. CAT scan: This test uses specialized x-rays to create crosssection images of organs and body tissues. Cholescintigraphy (HIDA scan): This test can determine whether the gallbladder is contracting correctly. A radioactive material is injected into the patient and makes its way to the gallbladder. The technician can then observe the movement of the gallbladder. Endoscopic ultrasound: This test combines ultrasound and endoscopy to look for gallstones. Endoscopic retrograde cholangiopancreatography: The doctor inserts an endoscope through the patient's mouth down to the small intestine and injects a dye to allow the bile ducts to be seen. The doctor can then remove gallstones that have moved into the ducts. How Are Gallstones Treated? Gallstones are usually treated with surgery to take out the gallbladder. The traditional operation is called an open cholecystectomy. A more recently developed procedure, called laparoscopic cholecystectomy, is less invasive, has fewer complications, and is used in most cases. Laparscopic cholecystectomy. During this procedure, instruments and a light and a camera are passed through several small incisions in the abdomen. The surgeon views the inside of the body by looking at a video monitor. This procedure is used in approximately 80% of gallbladder removals. After the surgery, the patient spends the night in the hospital.

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Open cholecystectomy. This is a more invasive procedure in which the surgeon makes incisions in the abdomen to remove the gallbladder. The patient stays in the hospital for a few days after the surgery.

If gallstones are in the bile ducts, endoscopic retrograde cholangiopancreatography (ERCP) may be used to find and remove them before or during gallbladder surgery. Are There Any Nonsurgical Treatments for Gallstones? If you have a medical condition and your doctor feels you shouldn't have gallstone surgery, he or she may prescribe the medications ursodiol (Actigall) or chenodiol (Chenix). These drugs work by dissolving cholesterol stones. Mild diarrhea is a side effect of both medications. The downside of using either medication is that you may have to take it for years to completely dissolve the stones. In addition, the stones may come back after you stop taking the drug

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Kidney Stones - Topic Overview What are kidney stones? Kidney stones are made of salts and minerals in the urine that stick together to form small "pebbles." They can be as small as grains of sand or as large as golf balls. They may stay in your kidneys or travel out of your body through the urinary tract . The urinary tract is the system that makes urine and carries it out of your body. It is made up of the kidneys, the tubes that connect the kidneys to the bladder (the ureters), the bladder, and the tube that leads from the bladder out of the body (the urethra). When a stone travels through a ureter, it may cause no pain. Or it may cause great pain and other symptoms. See pictures of a kidney stone What causes kidney stones? Kidney stones form when a change occurs in the normal balance of water, salts, minerals, and other things found in urine. The most common cause of kidney stones is not drinking enough water. Try to drink enough water to keep your urine clear (about 8 to 10 glasses of water a day). Some people are more likely to get kidney stones because of a medical condition or family history. Kidney stones may also be an inherited disease. If other people in your family have had them, you may have them too. What are the symptoms? Kidney stones often cause no pain while they are in the kidneys, but they can cause sudden, severe pain as they travel from the kidneys to the bladder. Call a doctor right away if you think you have kidney stones. Watch for severe pain in your side, belly, or groin or for urine that looks pink or red. You may also feel sick to your stomach (nausea) and may vomit. How are kidney stones diagnosed? You may first find out that you have kidney stones when you see your doctor or go to an emergency room with pain in your belly or side. Your doctor will ask you questions about your pain and lifestyle. He or she will examine you and may do imaging tests such as X-rays to look at your kidneys and urinary tract. You may need more tests if you have more than one stone or have a family history of stones. To find out the cause of your kidney stones, your doctor may order a blood test and ask you to collect your urine for 24 hours. This can help your doctor find out if you are likely to have more stones in the future. Kidney stones may not cause any pain. If this is the case, you may learn you have them when your doctor finds them during a test for another disease. and a stone traveling through a ureter .

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Urinary tract

The kidneys and bladder work together to make urine and remove it from your body. The kidneys filter waste products and water from the blood to form urine. The urine moves from the kidneys through tubes called ureters to the bladder, which stores the urine until it is full. From the bladder, urine leaves the body through another thin tube, the urethra. After the bladder starts to empty, it normally empties all of the urine. Kidney stone

Kidney stones are made of salts and minerals in the urine that stick together to form small "pebbles." They may form when the normal balance of water, salts, minerals, and other substances found in urine changes. How this balance changes determines the type of kidney stone you have. Most kidney stones are calcium-type-they form when the calcium levels in your urine change.

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Kidney stone in ureter

Kidney stones are made of salts and minerals in the urine that stick together to form small "pebbles." They are usually painless while they remain in the kidney, but they can cause severe pain as they break loose and travel through narrow tubes (ureters) to exit the body during urination. Symptoms of a kidney stone include severe pain on one side of the back, just below the rib cage (flank pain). The pain may spread to the lower abdomen, groin, and genital area. Other symptoms include blood in the urine (hematuria), painful or frequent urination (dysuria), and nausea and vomiting.

How are they treated? For most stones, your doctor will suggest drinking enough water to keep your urine clear, or about 8 to 10 glasses of water a day, to help flush the stones out. You may also need to take pain medicine. You can do this at home. Your doctor may give you a medicine to help the stone pass. If a stone is too large to pass on its own, or if it gets stuck in the urinary tract, you may need more treatment. About 1 or 2 out of every 10 kidney stones needs more than home treatment.1 The most common medical treatment is extracorporeal shock wave lithotripsy (ESWL). This uses shock waves to break a kidney stone into small pieces. The bits can pass out of your body in your urine. Other times, a doctor will need to remove the stone or place a small flexible plastic tube (called a stent) in the ureter to keep it open while stones pass. Will I have kidney stones again? After you have had kidney stones, you are more likely to have them again. You can help prevent them by drinking enough water to keep your urine clear, about 8 to 10 glasses of water a day. You may have to eat less of certain foods. Your doctor may also give you medicine that helps prevent stones from forming

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Types of kidney stones There are four main types of kidney stones. Calcium stones 1 Nearly 80% of all kidney stones are made of calcium compounds, especially calcium oxalate. Calcium phosphate and other minerals also may be present. Conditions that cause high calcium levels in the body, such as hyperparathyroidism, increase the risk of calcium stones. High levels of oxalate also increase the risk for calcium stones. Certain medicines may prevent calcium stones. Uric acid stones About 5% to 10% of kidney stones are made of uric acid, a waste product normally passed out of the body in the urine.1 You are more likely to have uric acid stones if you have: Low urine output. A diet high in animal protein, such as red meat. An increase in how much alcohol you drink. Gout. Inflammatory bowel disease. Certain medicines may prevent or dissolve uric acid stones. Struvite stones About 10% to 15% of kidney stones are struvite stones.1 They can also be called infection stones if they occur with kidney or urinary tract infections (UTIs). These types of kidney stones sometimes are also called staghorn calculi if they grow large enough. Struvite stones can be serious because they are often large stones and may occur with an infection. Medical treatment, including antibiotics and removal of the stone, is usually needed for struvite stones. Women are affected more than men because of their higher risk of urinary tract infections. Cystine stones Less than 1% of kidney stones are made of a chemical called cystine.1 Cystine stones are more likely to develop in families with a condition that results in too much cystine in the urine (cystinuria). Cystine stones may be prevented or dissolved with medicine, but this may be difficult and not very effective. If the stones cause blockage in the urinary tract or are too large, then removal of the stone will be needed.

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Kidney Stones - Treatment Overview Your first diagnosis of kidney stones often occurs when you see your doctor or go to an emergency room because you are in great pain. Your doctor may suggest that you wait for the stone to pass and take pain medicine or have a procedure to remove the stone. Most small stones [less than 5mm] move out of the body (pass) without the need for any treatment other than drinking extra fluids and taking pain medicine.1 The smaller a stone is, the more likely it is to pass on its own. About 9 out of every 10 stones smaller than 5mm and about 5 out of every 10 stones 5mm to 10mm pass on their own.1 Only 1 or 2 out of every 10 kidney stones need more than home treatment.1 The average time a stone takes to pass ranges between 1 and 3 weeks,1 and two-thirds of stones that pass on their own pass within 4 weeks of when the symptoms appeared.2 Not all kidney stones are diagnosed because of immediate symptoms. Your stone may not be causing you pain, and your doctor may find it during a routine exam or an exam for another condition or disease. In this case, you have the same treatment options as noted below. Treatment for your first stone If your doctor thinks the stone can pass on its own, and you feel you can deal with the pain, he or she may suggest home treatment, including: Drinking more fluids. You need to drink enough water to keep your urine clear, about 8 to 10 glasses a day. Try to drink 2 glasses of water every 2 hours while you are awake. If you have kidney, heart, or liver disease and are on fluid restrictions, talk with your doctor before increasing your fluid intake. Not drinking grapefruit juice. Drinking grapefruit juice may increase your risk for developing kidney stones. Using pain medicine. Nonprescription medicine, such as nonsteroidal anti-inflammatories (NSAIDs), may relieve your pain. Your doctor can prescribe stronger pain medicine if needed. Your doctor may prescribe medicine to help your body pass the stone. Calcium channel blockers and alpha-blockers have been shown to help kidney stones pass more quickly with very few side effects.11 Ask your doctor if one of these medicines can help you.

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If your pain is too severe, if the stones are blocking the urinary tract

, or if you also have an infection,

your doctor will probably suggest medical or surgical treatment. Your options are: Extracorporeal shock wave lithotripsy (ESWL). ESWL uses shock waves that pass easily through the body but are strong enough to break up a kidney stone. This is the most commonly used medical treatment for kidney stones. See a picture of ESWL puts a narrow telescope into the kidney through a cut in your back. He or she then removes the stone (lithotomy) or breaks it up and removes it (lithotripsy). This procedure may be used if ESWL does not work or if you have a very large stone. See a picture of nephrolithotomy . to the stone's location, Ureteroscopy. The surgeon passes a very thin telescope tube (ureteroscope) up the urinary tract where he or she uses instruments to remove the stone or break it up for easier removal. Occasionally, you may need a small hollow tube (ureteral stent) placed in the ureter for a short time to keep it open and drain urine and any stone pieces. Ureteroscopy is often used for stones that have moved from the kidney to the ureter. See a picture of ureteroscopy . Open surgery. The surgeon makes a cut in the side or the belly to reach the kidneys and remove the stone. This treatment is rarely used. . Percutaneous nephrolithotomy or nephrolithotripsy. The surgeon

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Extracorporeal shock wave lithotripsy (ESWL)

Extracorporeal shock wave lithotripsy (ESWL) uses shock waves to break a kidney stone into small pieces that can more easily travel through the urinary tract and pass from the body. You lie on a water-filled cushion. X-rays or ultrasound tests are used to precisely locate the stone. High-energy sound waves pass through your body without injuring it and break the stone into small pieces.

Percutaneous nephrolithotomy

Illustration copyright 2005 by Nucleus Communications, Inc. All rights reserved. http://www.nucleusinc.com Percutaneous nephrolithotomy or nephrolithotripsy uses a small incision in the person's back to remove kidney stones. The surgeon puts a hollow tube into the kidney and a probe through the tube. In

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nephrolithotomy, the surgeon removes the stone through the tube. In nephrolithotripsy, he or she breaks the stone up and then removes the fragments of the stone through the tube. Ureteroscopy

Illustration copyright 2005 by Nucleus Communications, Inc. All rights reserved. http://www.nucleusinc.com In a ureteroscopy, the surgeon passes a thin viewing instrument (ureteroscope) through the tube from the bladder out of the body (urethra) into the bladder, and then into the ureter to the location of the kidney stone. No incisions are made in the body. Your surgeon removes the kidney stone using forceps or an instrument with a small "basket." Smaller stones can be removed all in one piece. Larger stones may need to be broken up before the surgeon can remove them. Kidney Stones - Symptoms Kidney stones form in the kidney and if they stay in the kidney, they do not typically cause pain. When they travel out of the body through the tubes of the urinary tract (including the ureters, which connect the kidney to the bladder, or the urethra, which leads outside the body), their movement may cause: No symptoms, if the stone is small enough. Sudden, severe pain that gets worse in waves. Stones may cause intense pain in the back, side, abdomen, groin, or genitals. People who have had a kidney stone often describe the pain as "the worst pain I've ever had." Feeling sick to the stomach (nausea) and vomiting. Blood in the urine (hematuria), which can occur either with stones that stay in the kidney or with those that travel through the ureters.

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Frequent and painful urination, which may occur when the stone is in the ureter or after the stone has left the bladder and is in the urethra. Painful urination may occur when a urinary tract infection is also present.

Kidney Stones in Adults Kidney stones, one of the most painful of the urologic disorders, have beset humans for centuries. Scientists have found evidence of kidney stones in a 7,000-year-old Egyptian mummy. Unfortunately, kidney stones are one of the most common disorders of the urinary tract. Each year, people make almost 3 million visits to health care providers and more than half a million people go to emergency rooms for kidney stone problems. Most kidney stones pass out of the body without any intervention by a physician. Stones that cause lasting symptoms or other complications may be treated by various techniques, most of which do not involve major surgery. Also, research advances have led to a better understanding of the many factors that promote stone formation and thus better treatments for preventing stones. Introduction to the Urinary Tract The urinary tract, or system, consists of the kidneys, ureters, bladder, and urethra. The kidneys are two bean-shaped organs located below the ribs toward the middle of the back, one on each side of the spine. The kidneys remove extra water and wastes from the blood, producing urine. They also keep a stable balance of salts and other substances in the blood. The kidneys produce hormones that help build strong bones and form red blood cells.

The urinary tract. Narrow tubes called ureters carry urine from the kidneys to the bladder, an oval-shaped chamber in the lower abdomen. Like a balloon, the bladders elastic walls stretch and expand to store urine. They flatten together when urine is emptied through the urethra to outside the body. What is a kidney stone? A kidney stone is a hard mass developed from crystals that separate from the urine within the urinary tract. Normally, urine contains chemicals that prevent or inhibit the crystals from forming. These inhibitors

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do not seem to work for everyone, however, so some people form stones. If the crystals remain tiny enough, they will travel through the urinary tract and pass out of the body in the urine without being noticed. Kidney stones may contain various combinations of chemicals. The most common type of stone contains calcium in combination with either oxalate or phosphate. These chemicals are part of a persons normal diet and make up important parts of the body, such as bones and muscles. A less common type of stone is caused by infection in the urinary tract. This type of stone is called a struvite or infection stone. Another type of stone, uric acid stones, are a bit less common, and cystine stones are rare.

Kidney stones in the kidney, ureter, and bladder. Urolithiasis is the medical term used to describe stones occurring in the urinary tract. Other frequently used terms are urinary tract stone disease and nephrolithiasis. Doctors also use terms that describe the location of the stone in the urinary tract. For example, a ureteral stoneor ureterolithiasisis a kidney stone found in the ureter. To keep things simple, the general term kidney stones is used throughout this fact sheet. Gallstones and kidney stones are not related. They form in different areas of the body. Someone with a gallstone is not necessarily more likely to develop kidney stones. Who gets kidney stones? For unknown reasons, the number of people in the United States with kidney stones has been increasing over the past 30 years. In the late 1970s, less than 4 percent of the population had stone-forming disease. By the early 1990s, the portion of the population with the disease had increased to more than 5 percent. Caucasians are more prone to develop kidney stones than African Americans. Stones occur more frequently in men. The prevalence of kidney stones rises dramatically as men enter their 40s and continues to rise into their 70s. For women, the prevalence of kidney stones peaks in their 50s. Once a person gets more than one stone, other stones are likely to develop. What causes kidney stones? Doctors do not always know what causes a stone to form. While certain foods may promote stone formation in people who are susceptible, scientists do not believe that eating any specific food causes stones to form in people who are not susceptible.

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A person with a family history of kidney stones may be more likely to develop stones. Urinary tract infections, kidney disorders such as cystic kidney diseases, and certain metabolic disorders such as hyperparathyroidism are also linked to stone formation. In addition, more than 70 percent of people with a rare hereditary disease called renal tubular acidosis develop kidney stones.

Shapes of various stones. Sizes are usually smaller than shown here. Cystinuria and hyperoxaluria are two other rare, inherited metabolic disorders that often cause kidney stones. In cystinuria, too much of the amino acid cystine, which does not dissolve in urine, is voided, leading to the formation of stones made of cystine. In patients with hyperoxaluria, the body produces too much oxalate, a salt. When the urine contains more oxalate than can be dissolved, the crystals settle out and form stones. Hypercalciuria is inherited, and it may be the cause of stones in more than half of patients. Calcium is absorbed from food in excess and is lost into the urine. This high level of calcium in the urine causes crystals of calcium oxalate or calcium phosphate to form in the kidneys or elsewhere in the urinary tract. Other causes of kidney stones are hyperuricosuria, which is a disorder of uric acid metabolism; gout; excess intake of vitamin D; urinary tract infections; and blockage of the urinary tract. Certain diuretics, commonly called water pills, and calcium-based antacids may increase the risk of forming kidney stones by increasing the amount of calcium in the urine. Calcium oxalate stones may also form in people who have chronic inflammation of the bowel or who have had an intestinal bypass operation, or ostomy surgery. As mentioned earlier, struvite stones can form in people who have had a urinary tract infection. People who take the protease inhibitor indinavir, a medicine used to treat HIV infection, may also be at increased risk of developing kidney stones. Foods and Drinks Containing Oxalate People prone to forming calcium oxalate stones may be asked by their doctor to limit or avoid certain foods if their urine contains an excess of oxalate. High-oxalate foodshigher to lower rhubarb spinach beets

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swiss chard wheat germ soybean crackers peanuts okra chocolate black Indian tea sweet potatoes

Foods that have medium amounts of oxalate may be eaten in limited amounts. Medium-oxalate foodshigher to lower grits grapes celery green pepper red raspberries fruit cake strawberries marmalade liver

What are the symptoms of kidney stones? Kidney stones often do not cause any symptoms. Usually, the first symptom of a kidney stone is extreme pain, which begins suddenly when a stone moves in the urinary tract and blocks the flow of urine. Typically, a person feels a sharp, cramping pain in the back and side in the area of the kidney or in the lower abdomen. Sometimes nausea and vomiting occur. Later, pain may spread to the groin. If the stone is too large to pass easily, pain continues as the muscles in the wall of the narrow ureter try to squeeze the stone into the bladder. As the stone moves and the body tries to push it out, blood may appear in the urine, making the urine pink. As the stone moves down the ureter, closer to the bladder, a person may feel the need to urinate more often or feel a burning sensation during urination. If fever and chills accompany any of these symptoms, an infection may be present. In this case, a person should contact a doctor immediately. How are kidney stones diagnosed? Sometimes silent stonesthose that do not cause symptomsare found on x rays taken during a general health exam. If the stones are small, they will often pass out of the body unnoticed. Often, kidney stones are found on an x ray or ultrasound taken of someone who complains of blood in the urine or sudden pain. These diagnostic images give the doctor valuable information about the stones size and location. Blood and urine tests help detect any abnormal substance that might promote stone formation. The doctor may decide to scan the urinary system using a special test called a computerized tomography (CT) scan or an intravenous pyelogram (IVP). The results of all these tests help determine the proper treatment.

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Preventing Kidney Stones A person who has had more than one kidney stone may be likely to form another; so, if possible, prevention is important. To help determine their cause, the doctor will order laboratory tests, including urine and blood tests. The doctor will also ask about the patients medical history, occupation, and eating habits. If a stone has been removed, or if the patient has passed a stone and saved it, a stone analysis by the laboratory may help the doctor in planning treatment. The doctor may ask the patient to collect urine for 24 hours after a stone has passed or been removed. For a 24-hour urine collection, the patient is given a large container, which is to be refrigerated between trips to the bathroom. The collection is used to measure urine volume and levels of acidity, calcium, sodium, uric acid, oxalate, citrate, and creatininea product of muscle metabolism. The doctor will use this information to determine the cause of the stone. A second 24-hour urine collection may be needed to determine whether the prescribed treatment is working. How are kidney stones treated? Fortunately, surgery is not usually necessary. Most kidney stones can pass through the urinary system with plenty of water2 to 3 quarts a dayto help move the stone along. Often, the patient can stay home during this process, drinking fluids and taking pain medication as needed. The doctor usually asks the patient to save the passed stone(s) for testing. It can be caught in a cup or tea strainer used only for this purpose. Lifestyle Changes A simple and most important lifestyle change to prevent stones is to drink more liquidswater is best. Someone who tends to form stones should try to drink enough liquids throughout the day to produce at least 2 quarts of urine in every 24-hour period. In the past, people who form calcium stones were told to avoid dairy products and other foods with high calcium content. Recent studies have shown that foods high in calcium, including dairy products, may help prevent calcium stones. Taking calcium in pill form, however, may increase the risk of developing stones. Patients may be told to avoid food with added vitamin D and certain types of antacids that have a calcium base. Someone who has highly acidic urine may need to eat less meat, fish, and poultry. These foods increase the amount of acid in the urine. To prevent cystine stones, a person should drink enough water each day to dilute the concentration of cystine that escapes into the urine, which may be difficult. More than a gallon of water may be needed every 24 hours, and a third of that must be drunk during the night. Medical Therapy A doctor may prescribe certain medications to help prevent calcium and uric acid stones. These medicines control the amount of acid or alkali in the urine, key factors in crystal formation. The medicine allopurinol may also be useful in some cases of hyperuricosuria. Doctors usually try to control hypercalciuria, and thus prevent calcium stones, by prescribing certain diuretics, such as hydrochlorothiazide. These medicines decrease the amount of calcium released by the kidneys into the urine by favoring calcium retention in bone. They work best when sodium intake is low.

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Rarely, patients with hypercalciuria are given the medicine sodium cellulose phosphate, which binds calcium in the intestines and prevents it from leaking into the urine. If cystine stones cannot be controlled by drinking more fluids, a doctor may prescribe medicines such as Thiola and Cuprimine, which help reduce the amount of cystine in the urine. For struvite stones that have been totally removed, the first line of prevention is to keep the urine free of bacteria that can cause infection. A patients urine will be tested regularly to ensure no bacteria are present. If struvite stones cannot be removed, a doctor may prescribe a medicine called acetohydroxamic acid (AHA). AHA is used with long-term antibiotic medicines to prevent the infection that leads to stone growth. People with hyperparathyroidism sometimes develop calcium stones. Treatment in these cases is usually surgery to remove the parathyroid glands, which are located in the neck. In most cases, only one of the glands is enlarged. Removing the glands cures the patients problem with hyperparathyroidism and kidney stones. Surgical Treatment Surgery may be needed to remove a kidney stone if it does not pass after a reasonable period of time and causes constant pain is too large to pass on its own or is caught in a difficult place blocks the flow of urine causes an ongoing urinary tract infection damages kidney tissue or causes constant bleeding has grown larger, as seen on follow-up x rays

Until 20 years ago, open surgery was necessary to remove a stone. The surgery required a recovery time of 4 to 6 weeks. Today, treatment for these stones is greatly improved, and many options do not require major open surgery and can be performed in an outpatient setting. Extracorporeal Shock Wave Lithotripsy Extracorporeal shock wave lithotripsy (ESWL) is the most frequently used procedure for the treatment of kidney stones. In ESWL, shock waves that are created outside the body travel through the skin and body tissues until they hit the denser stones. The stones break down into small particles and are easily passed through the urinary tract in the urine. Several types of ESWL devices exist. Most devices use either x rays or ultrasound to help the surgeon pinpoint the stone during treatment. For most types of ESWL procedures, anesthesia is needed. In many cases, ESWL may be done on an outpatient basis. Recovery time is relatively short, and most people can resume normal activities in a few days. Complications may occur with ESWL. Some patients have blood in their urine for a few days after treatment. Bruising and minor discomfort in the back or abdomen from the shock waves can occur. To reduce the risk of complications, doctors usually tell patients to avoid taking aspirin and other medicines that affect blood clotting for several weeks before treatment. Sometimes, the shattered stone particles cause minor blockage as they pass through the urinary tract and cause discomfort. In some cases, the doctor will insert a small tube called a stent through the bladder

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into the ureter to help the fragments pass. Sometimes the stone is not completely shattered with one treatment, and additional treatments may be needed. As with any interventional, surgical procedure, potential risks and complications should be discussed with the doctor before making a treatment decision.

Extracorporeal shock wave lithotripsy. Percutaneous Nephrolithotomy Sometimes a procedure called percutaneous nephrolithotomy is recommended to remove a stone. This treatment is often used when the stone is quite large or in a location that does not allow effective use of ESWL. In this procedure, the surgeon makes a tiny incision in the back and creates a tunnel directly into the kidney. Using an instrument called a nephroscope, the surgeon locates and removes the stone. For large stones, some type of energy probeultrasonic or electrohydraulicmay be needed to break the stone into small pieces. Often, patients stay in the hospital for several days and may have a small tube called a nephrostomy tube left in the kidney during the healing process. One advantage of percutaneous nephrolithotomy is that the surgeon can remove some of the stone fragments directly instead of relying solely on their natural passage from the kidney.

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Percutaneous nephrolithotomy. Ureteroscopic Stone Removal Although some stones in the ureters can be treated with ESWL, ureteroscopy may be needed for midand lower-ureter stones. No incision is made in this procedure. Instead, the surgeon passes a small fiberoptic instrument called a ureteroscope through the urethra and bladder into the ureter. The surgeon then locates the stone and either removes it with a cage-like device or shatters it with a special instrument that produces a form of shock wave. A small tube or stent may be left in the ureter for a few days to help urine flow. Before fiber optics made ureteroscopy possible, physicians used a similar blind basket extraction method. But this technique is rarely used now because of the higher risks of damage to the ureters.

Ureteroscopic stone removal. Hope through Research The Division of Kidney, Urologic, and Hematologic Diseases of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) funds research on the causes, treatments, and prevention of kidney stones. The NIDDK is part of the National Institutes of Health in Bethesda, MD.

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New medicines and the growing field of lithotripsy have greatly improved the treatment of kidney stones. Still, NIDDK researchers and grantees seek to answer questions such as Why do some people continue to have painful stones? How can doctors predict, or screen, those at risk for getting stones? What are the long-term effects of lithotripsy? Do genes play a role in stone formation? What is the natural substance(s) found in urine that blocks stone formation? Definition Kidney stones (renal lithiasis) are small, hard deposits of mineral and acid salts on the inner surfaces of your kidneys. Normally, the substances that make up kidney stones are diluted in the urine. When urine is concentrated, though, minerals may crystallize, stick together and solidify. The result is a kidney stone. Most kidney stones contain calcium. Passing kidney stones can be excruciating. The pain they cause typically starts in your side or back, just below your ribs, and radiates to your lower abdomen and groin. Painful as they are, kidney stones usually cause no permanent damage. Medical intervention apart from pain medication is often unnecessary. Still, it's important to find out what type of kidney stone you have and why it developed. Some of the underlying causes of kidney stones can be treated to prevent new stones from forming. If no specific treatment exists, you may be able to stave off additional kidney stones simply by drinking more water and making a few dietary changes.

Symptoms Until a kidney stone moves into the ureter the tube connecting the kidney and bladder you may not know you have it. At that point, these signs and symptoms may occur: Pain in the side and back, below the ribs Fluctuations in pain intensity, with periods of pain lasting 20 to 60 minutes Pain waves radiating from the side and back to the lower abdomen and groin Bloody, cloudy or foul-smelling urine Pain on urination Nausea and vomiting Persistent urge to urinate Fever and chills if an infection is present

Kidney stones that don't cause these symptoms may show up on X-rays when you seek medical care for other problems, such as blood in your urine or recurring urinary tract infections. Causes Kidney stones

Your kidneys are two bean-shaped organs, each about the size of your fist. They're located in back of your abdomen on each side of your spine, and their main function is to remove excess fluid, unneeded

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electrolytes and wastes from your blood in the form of urine. The ureters carry urine from your kidneys to your bladder, where it's stored until you eliminate it from your body. Kidney stones form when the components of urine fluid and various minerals and acids are out of balance. When this happens, your urine contains more crystal-forming substances, such as calcium and uric acid, than the available fluid can dilute. At the same time, your urine may be short of substances that keep crystals from sticking together and becoming stones. Kidney stones are also prone to develop in highly acidic or highly alkaline urine. Problems in the way your system absorbs and eliminates calcium and other substances create the conditions for kidney stones to form. Sometimes, the underlying cause is an inherited metabolic disorder or kidney disease. Gout promotes specific types of kidney stones, as does inflammatory bowel disease. So do some drugs, including furosemide (Lasix), used in treating heart failure and high blood pressure; topiramate (Topamax), an anti-seizure drug; and indinavir (Crixivan), which is used to treat human immunodeficiency virus, the cause of AIDS. It's common, however, for kidney stones to have no definite, single cause. A number of factors, often in combination, create the conditions in which susceptible people develop kidney stones. Most kidney stones contain crystals of more than one type. Determining the type that makes up the bulk of the stone usually a combination of calcium compounds helps identify the underlying cause. The best preventive approach after your first kidney stone also depends partly on the stone's composition. Calcium stones. Roughly four out of five kidney stones are calcium stones, usually in the form of calcium oxalate. Oxalate is found in some fruits and vegetables, but the liver produces most of the body's oxalate supply. Dietary factors, high doses of vitamin D, intestinal bypass surgery and several different metabolic disorders can increase the concentration of calcium or oxalate in urine. Struvite stones. Found more often in women, struvite stones are almost always the result of urinary tract infections. Struvite stones may be large enough to fill most of a kidney's urinecollecting space, forming a characteristic stag's-horn shape. Uric acid stones. These stones are formed of uric acid, a byproduct of protein metabolism. You're more likely to develop uric acid stones if you eat a high-protein diet. Gout also leads to uric acid stones. Certain genetic factors and disorders of the blood-producing tissues also may predispose you to the condition. Cystine stones. These stones represent only a small percentage of kidney stones. They form in people with a hereditary disorder that causes the kidneys to excrete excessive amounts of certain amino acids (cystinuria).

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Kidney stones

Kidney stones sometimes pass into one of the two tubes (ureters) leading from your kidneys to your bladder. Risk factors These factors may increase your risk of developing kidney stones: Lack of fluids. If you don't drink enough fluids, especially water, your urine is likely to have higher concentrations of substances that can form stones. That's also why you're more likely to form kidney stones if you live in a hot, dry climate or exercise strenuously without replacing lost fluids. Family or personal history. If someone in your family has kidney stones, you're more likely to develop stones too. And if you've already had one or more kidney stones, you're at increased risk of developing another. Age and sex. Most people who develop kidney stones are between 20 and 70 years of age. Men are more likely to develop kidney stones than are women. Diet. A high-protein, high-sodium and low-calcium diet may increase your risk of some types of kidney stones. Limited activity. You're more prone to develop kidney stones if you're bedridden or very sedentary for a long period of time. That's partly because limited activity can cause your bones to release more calcium. Obesity. High body mass index (BMI), increased waist size and weight gain have been linked to kidney stones in long-term studies of large populations. The relationship is strongest in women. High blood pressure. Having high blood pressure doubles your risk of forming kidney stones. Gastric bypass surgery, inflammatory bowel disease or chronic diarrhea. Changes in the digestive process affect your absorption of calcium and increase the levels of stone-forming substances in your urine.

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Tests and diagnosis Many kidney stones go unnoticed until they cause acute symptoms specifically, the pain of a stone going through your ureter. Sometimes, however, kidney stones are discovered in the course of looking for the cause of chronic urinary tract infections or blood in the urine. If your doctor suspects you have kidney stones, you're likely to have a blood analysis to look for excess calcium or uric acid and a 24-hour collection of urine to check whether you're excreting too many stoneforming minerals or too few inhibiting substances. You may also have one or more of the following imaging tests: Computerized tomography (CT) scan. This imaging test has become the standard of care for evaluating acute kidney stones. It's rapidly performed, can identify stones regardless of composition and doesn't require the use of contrast dye. Abdominal X-ray. An abdominal X-ray can visualize most kidney stones and can help to judge changes in the size of a stone over time. Ultrasound. Instead of X-rays, this diagnostic technique combines high-frequency radio waves and computer processing to view your internal organs. It's safe, painless and noninvasive, but it may miss small stones, especially if they're located in a ureter or your bladder. Intravenous pyelography (excretory urogram). This study can be useful in determining the location of stones in the urinary system and can define the degree of blockage caused by a stone. A contrast dye is injected into a vein in your arm and a series of X-rays is taken as the dye moves through your kidneys, ureters and bladder. This study has largely been replaced by the CT scan but is still useful in limited circumstances.

If you're about to pass a stone, your doctor may ask you to urinate through a strainer so that the stone can be recovered and analyzed. Complications If a stone stays inside one of your kidneys, it usually doesn't cause a problem unless it becomes so large it blocks the flow of urine. This can cause pressure and pain, along with the risk of kidney damage, bleeding and infection. Smaller stones may partially block the thin tubes that connect each kidney to your bladder or the outlet from the bladder itself. These stones may cause ongoing urinary tract infections or kidney damage if left untreated. Treatments and drugs Treatment for kidney stones varies, depending on the type of stone and the cause. You may be able to move a stone through your urinary tract simply by drinking plenty of water as much as 2 to 3 quarts (1.9 to 2.8 liters) a day and by staying physically active. Stones that can't be treated with more-conservative measures either because they're too large to pass on their own or because they cause bleeding, kidney damage or ongoing urinary tract infections may need professional treatment. Procedures include: Extracorporeal shock wave lithotripsy (ESWL). This is a commonly used procedure for treating kidney stones. It uses shock waves to break the stones into tiny pieces that are then passed in your urine. In some cases, you may be partially submerged in a tub of water during the

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procedure. In others, you may lie on a soft cushion. You'll generally require sedation or light anesthesia due to moderate pain caused by the shock waves. A loud noise is produced each time a shock wave is generated, and you'll wear earphones to protect your hearing. Your doctor will likely use X-rays or ultrasound to help determine the position of the stone as well as to monitor the status of the stone during treatment. Complications that may occur with ESWL include blood in the urine, bruising on the back or abdomen, bleeding around the kidney and other adjacent organs, and discomfort as the stone fragments pass through the urinary tract. In addition, if the stone doesn't shatter completely, you may need a second round of ESWL or ureteroscopic stone removal. After treatment, it may take months for all the stone fragments to pass. Percutaneous nephrolithotomy. When ESWL isn't effective, or the stone is very large, your surgeon may remove your kidney stone through a small incision in your back using an instrument called a nephroscope. Ureteroscopic stone removal. This procedure may be used to remove a stone lodged in a ureter. The stone is snared with a small instrument (ureteroscope) that's passed into the ureter through your bladder. Ultrasound or laser energy also can be directed through the scope to shatter the stone. These methods work especially well on stones in the lower part of the ureter. Parathyroid surgery. Some calcium stones are caused by overactive parathyroid glands, which are located on the four corners of your thyroid gland, just below your Adam's apple. When these glands produce too much parathyroid hormone, your body's level of calcium can become too high, resulting in excessive excretion of calcium in your urine. Most often, this is the result of a small benign tumor in one of your four parathyroid glands. A doctor can surgically remove the tumor.

Prevention In many cases, you can prevent kidney stones by making a few lifestyle changes. If these measures aren't effective and blood and urine tests reveal a correctable chemical imbalance or that the stones you have are getting bigger, your doctor may prescribe certain medications. Lifestyle changes For people with a history of kidney stones, doctors usually recommend passing at least 2.5 quarts (2.3 liters) of urine a day. To do this, you'll need to drink about 14 cups (3.3 liters) of fluids every day and even more if you live in a hot, dry climate. What should you drink? Water is best. Include a glass of lemonade every day, too. Make your own with real lemons, or use a liquid or frozen concentrate, but avoid powdered lemonade mixes. Lemonade increases the levels of citrate in your urine, and citrate helps prevent stone formation. In addition, if you tend to form calcium oxalate stones, your doctor may recommend restricting foods rich in oxalates. These include rhubarb, star fruit, beets, beet greens, collards, okra, refried beans, spinach, Swiss chard, sweet potatoes, sesame seeds, almonds and soy products. What's more, studies show that an overall diet low in salt and very low in animal protein can greatly reduce your chance of developing kidney stones. As a general rule, restricting your intake of calcium doesn't seem to lower your risk. In fact, researchers have found that women with a high calcium intake are less likely to develop kidney stones than are women who consume less calcium. Why? Dietary calcium binds with oxalates in the gastrointestinal tract so that oxalates can't be absorbed from the intestine and excreted by the kidney to form stones.

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An exception to this rule occurs when an individual absorbs too much dietary calcium from the intestine. In such a circumstance, restricting calcium intake is useful. Calcium supplements seem to have the same protective effect as dietary calcium, but only if they're taken with meals. Medications Medications can control the level of acidity or alkalinity in your urine and may be helpful in people who form certain kinds of stones. The type of medication your doctor prescribes will depend on the kind of kidney stones you have: Calcium stones. To help prevent calcium stones from forming, your doctor may prescribe a thiazide diuretic or a phosphate-containing preparation. If you have calcium stones because of a condition known as renal tubular acidosis, your doctor may suggest taking sodium bicarbonate or potassium bicarbonate. Uric acid stones. Your doctor may prescribe allopurinol (Zyloprim, Aloprim) to reduce uric acid levels in your blood and urine and a medicine to keep your urine alkaline. In some cases, allopurinol and an alkalinizing agent may dissolve the uric acid stones. Struvite stones. To prevent struvite stones, the first goal is to keep urine free of bacteria that cause infection. Long-term use of antibiotics in small doses may be useful to achieve this goal. Cystine stones. Cystine stones are the hardest stones and the most difficult to treat. Your doctor may prescribe certain medications to alkalinize the urine or to bind the cystine in the urine in addition to recommending an extremely high urine output.

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