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

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

(pancreatitis). These symptoms may also be a

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
5

have the gallbladder removed. Exercising 2 to 3 hours per week reduced the women's risk by 20%.

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

(cholecystectomy) removes the gallbladder and gallstones through

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

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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.

Excessive body weight.

How Well It Works

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:

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genetics (others in your family have had gallstones)

body weight

decreased motility (movement) of the gallbladder

diet

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).

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Nausea

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

and a stone traveling through a ureter

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.

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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

Percutaneous nephrolithotomy or nephrolithotripsy. The surgeon

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

Ureteroscopy. The surgeon passes a very thin telescope tube

(ureteroscope) up the urinary tract

to the stone's location,

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.

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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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