Gallbladder Disease

A gallstone is a lump of hard material usually ranging in size from a grain of sand to 3-4 cms. They are formed inside the gall bladder as a result of precipitation of cholesterol and bile salts from the bile.

Types of gallstones and causes

• Cholesterol stones
• Pigment stones
• Mixed stones – the most common type. They are comprised of cholesterol and salts

Cholesterol stones are usually yellow-green and are made primarily of hardened cholesterol. They account for about 80 percent of gallstones. Scientists believe cholesterol stones form when bile contains too much cholesterol, too much bilirubin, or not enough bile salts, or when the gallbladder does not empty as it should for some other reason.

Pigment stones are small, dark stones made of bilirubin. The exact cause is not known. They tend to develop in people who have cirrhosis, biliary tract infections, and hereditary blood disorders such as sickle cell anemia in which too much bilirubin is formed.

Other causes are related to excess excretion of cholesterol by liver through bile. They include the following.

• Gender. Women between 20 and 60 years of age are twice as likely to develop gallstones as men.
• Obesity. Obesity is a major risk factor for gallstones, especially in women.
• Estrogen. Excess estrogen from pregnancy, hormone replacement therapy, or birth control pills
• Cholesterol-lowering drugs.
• Diabetes. People with diabetes generally have high levels of fatty acids called triglycerides.
• Rapid weight loss. As the body metabolizes fat during rapid weight loss, it causes the liver to secrete extra cholesterol into bile, which can cause gallstones.

Symptoms

Many people with gallstones have no symptoms. These patients are said to be asymptomatic, and these stones are called “silent stones.” Gallstone symptoms are similar to those of heart attack, appendicitis, ulcers, irritable bowel syndrome, hiatal hernia, pancreatitis, and hepatitis. So accurate diagnosis is important.

Symptoms may vary and often follow fatty meals, and they may occur during the night.

• Abdominal bloating
• Recurring intolerance of fatty foods
• Steady pain in the upper abdomen that increases rapidly and lasts from 30 minutes to several hours
• Pain in the back between the shoulder blades
• Pain under the right shoulder
• Nausea or vomiting
• Indigestion & belching

Diagnoses

Ultrasound is the most sensitive and specific test for gallstones.

Other diagnostic tests may include

• Computed tomography (CT) scan may show the gallstones or complications
• Endoscopic retrograde cholangiopancreatography (ERCP). The patient swallows an endoscope–a long, flexible, lighted tube connected to a computer and TV monitor. The doctor guides the endoscope through the stomach and into the small intestine. The doctor then injects a special dye that temporarily stains the ducts in the biliary system. ERCP is used to locate and remove stones in the ducts
• Blood tests. Blood tests may be used to look for signs of infection, obstruction, pancreatitis, or jaundice
• In the event of negative ultrasound a CCK HIDA Scan may be ordered to screen for a non-functioning gallbladder

Course of illness

Bile-duct blockage and infection caused by stones in the biliary tract can be a life-threatening illness. With prompt diagnosis and treatment, the outcome is usually very good.

Complications

The obstruction caused by gall stone may lead to Biliary colic, Inflammation of gall bladder (Cholecystitis) . Other complications may include

• Cirrhosis- Cirrhosis is the result of chronic liver disease that causes scarring of the liver (fibrosis – nodular regeneration) and liver dysfunction
• Cholangitis- Cholangitis is an infection of the common bile duct, which carries bile (which helps in digestion) from the liver to the gallbladder and then to the intestines

Primary Treatment – Surgery

Surgery to remove the gallbladder is the most common way to treat symptomatic gallstones. The most common operation is called laparoscopic cholecystectomy. For this operation, the surgeon makes several tiny incisions in the abdomen and inserts surgical instruments and a miniature video camera into the abdomen. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close up view of the organs and tissues. While watching the monitor, the surgeon uses the instruments to carefully separate the gallbladder from the liver, ducts, and other structures.

If gallstones are in the bile ducts, the physician (usually a gastroenterologist) may use endoscopic retrograde cholangiopancreatography (ERCP) to locate and remove them before or during the gallbladder surgery.

Cholecystectomy

Of all surgical procedures for which laparoscopy is an option, cholecystectomy – gallbladder removal – is the most widely recognized.

Cholecystectomy is the surgical removal of the gallbladder. Using advanced laparoscopic technology, it is now possible to remove the gallbladder through a tiny incisions in front of the abdomen.

A specialist trained in laparoscopic procedures will recognize any adjunct problems encountered, and be in a position to deal with them, for example adhesions, cysts, or hernias.

Indications for Laparoscopic Gall Bladder removal (Cholecystectomy)

• If an attack hasn’t settled after 12 hours
• If there are complications such as jaundice, pancreatitis
• If patient suffers recurrent pain or vomiting
• If patient suffers cholangitis

• • What are the Benefits?

    The main benefit of this procedure is that it is minimally invasive surgery. Minimally invasive surgery means “Less Pain” and “Faster Recovery”.

    There is no incision pain as occurs with standard abdominal surgery. So the recovery time is much quicker. Also, there is no scar on the abdomen.

  • Is laparoscopy always advised?

    There are very few instances when laparoscopic surgery is not preferable to conventional surgery for cholecystectomy. This is especially true when the surgical and nursing team is well experienced in the procedures and post-operative care.

    The only real contraindication is if the anesthetic risk is too high. Other, lesser contraindications – such as during the first trimester of pregnancy – need not pose a problem to the experienced laparoscopic surgeon.

  • Risks & Complications

    Like any abdominal surgery, Laparoscopic Cholecystectomy carries some risks. Even though infrequent, it still carries some of the same risks as general surgery. Current medical reports indicate that the low complication rate is about the same for this procedure as for standard gallbladder surgery.

    Complications are rare and may include:

    • Bleeding & infection may occur but is rare with experienced surgeons
    • In a few cases, the gallbladder cannot be safely removed by laparoscopy. Standard open abdominal surgery is then immediately performed
    • Nausea and vomiting may occur after the surgery
    • Injury to the bile ducts, blood vessels, or intestine can occur, requiring corrective surgery