Gallstones

The gallbladder is a pear shaped sac located on the right side of the abdomen, just below the liver. It stores bile fluid, a digestive juice produced- For information about lap by the liver that is used in the breakdown of dietary fats. The gallbladder extracts water from its store of bile until the liquid becomes highly concentrated. The presence of fatty foods triggers the gallbladder to squeeze its bile concentrate into the small intestine via the common bile duct.

Gallstones (biliary calculi) are small, hard, stone-like deposits made from cholesterol, bile pigment and calcium salts. They are a common disorder of the digestive system, and can vary in size from a small grain of sand to a golf ball.

They affect approximately 15 per cent of people aged 50 years and over

Types of Gallstones:

• Mixed stones – the most common type. They are made up of cholesterol and salts and tend to develop in batches.
• Cholesterol stones: These are yellowish-green in colour and chiefly made up of hardened cholesterol.
• Pigment stones: These are dark and small, usually present in numbers and primarily made of bilirubin, a yellowish bile pigment.

In the majority of cases, gallstones do not cause any problems. However, prompt treatment is needed if stones block the bile duct and cause complications such as inflammation and infection of the gallbladder (cholecystitis) or of the pancreas (pancreatitis).

Causes:

There is no single cause of gallstones.

• Some things that may cause gallstones to form include the crystallisation of excess cholesterol in bile, over production of cholesterol by the liver and failure of the gallbladder to empty completely.

Risk Factors:

• Being female – Gallstones are more common in women of childbearing years.
• Being overweight – Obesity increases the risk of gallstones.
• Genetic factors and a family history of gallstones.

Symptoms:

Gallstones can occur with or without producing symptoms.

Silent gallstones:

About 70 per cent of people who have gallstones do not have noticeable symptoms and are often unaware that they have them. Gallstones may be discovered only during investigations for other conditions. For this reason, they are sometimes called ‘silent’ gallstones.

Symptomatic gallstones:

Symptoms of gallstones generally occur when a stone becomes lodged in one of the ducts (tubes) that carry the bile to and from the gallbladder (these include the cystic duct and the bile ducts).

Symptoms requiring immediate attention

The most common symptom of gallstones is known as biliary colic. Attacks of biliary colic are commonly recurrent (repeating). They often occur after a fatty meal, as fat intake stimulates the gallbladder to squeeze its stored bile into the small intestine to help digestion.

The pain is described as:

• Intermittent that is felt in the upper right section or centre of your abdomen and may run through to your back, between the shoulder blades or into your right shoulder;
• Often comes on suddenly, increases quickly and may last from a few minutes to several hours before subsiding; and
• May be moderate to severe.
• Nausea and vomiting may be associated with the pain.
• Fever, sweating and chills.
• Jaundice – a yellowing of the skin or whites of the eyes.

If you have any of these serious symptoms you should seek medical care immediately.

Biliary colic usually settles when the gallstone moves, unblocking the affected bile duct(s) and releasing the pressure on the gallbladder. If the duct remains blocked, complications can result.

These signs and symptoms can indicate serious gallstone complications.

Fever and severe abdominal pain (with or without nausea and vomiting) that does not get better after a few hours may indicate infection or inflammation of the:

• Gallbladder (a condition known as cholecystitis);
• Bile duct (cholangitis); or
• Pancreas (pancreatitis).
• If you have any of these serious symptoms you should seek medical care immediately.
• Biliary colic usually settles when the gallstone moves, unblocking the affected bile duct(s) and releasing the pressure on the gallbladder. If the duct remains blocked, complications can result.

Diagnosis:

A preliminary diagnosis is made on a full patient history of symptoms especially the location, type and severity of the pain.

Further tests may include:

• Blood tests
  • Liver function tests (LFTs), which are blood tests that can show evidence of gallbladder disease.
  • A check of the blood’s amylase or lipase levels to look for inflammation of the pancreas.
  • A full blood count (FBC), which looks at levels of different types of blood cells such as white blood cells.
• Ultrasound – This may be requested by you surgeon. It uses sound waves to image and make pictures of the intra-abdominal organs including the gallbladder.
• Computed tomography (CT) scan – This is rarely performed but may be done in an emergency situation.

Treatment:

While dietary modifications may help with "silent" stones, for symptomatic gallstones pain medication and surgery are the only effective treatments.

Surgery

‘Cholecystectomy’ – the term that doctors use for gallbladder removal – can be performed through open surgery or ‘keyhole’ laparoscopic surgery.

Open cholecystectomy – Open Cholecystectomy is now uncommon and occurs in about 1% of patients. However, sometimes an operation that starts out as a laparoscopic cholecystectomy turns into open surgery if the surgeon encounters unexpected difficulties such as not being able to see the gallbladder properly.

Laparoscopic cholecystectomy

During a laparoscopic cholecystectomy, the surgeon enters the abdomen by placing a cannula or port (narrow tube-like instrument) into the abdomen through a small incision measuring approximately 1.5 cm. Carbon dioxide (CO2) gas is then pumped into the abdomen through the port to create more space inside the abdomen. The laparoscope is a tiny telescope connected to a video camera. This is passed through the cannula to allow the surgeon to see a magnified, lighted view of the internal organs on a high-definition monitor screen. The television monitor guides the surgeon in the insertion of slender specialised instruments to where the gallbladder is located. Your surgeon first identifies the cystic duct between the gall bladder and bile duct. When clearly located the cystic duct and the blood vessels supplying the gall bladder are cut and closed, allowing the organ to be removed safely.

As many as five small incisions may be made to allow the surgeon and an assistant to effectively see and work inside the abdomen.

The surgery is performed under general anaesthesia.

A procedure called a cholangiogram may be performed during the surgery, which uses X-rays and a dye injected into the body to view the bile ducts. This is done to identify gallstones that could have been missed, obstructions or narrowing of the bile ducts. If any gallstones remain in the bile duct your surgeon may use a special instrument to remove these at the time of surgery.

Rarely an operation that starts out as a laparoscopic colectomy turns into open surgery if the surgeon encounters unexpected technical difficulties.

Post-operative recovery

Following laparoscopic cholecystectomy you can expect to go home the following day with the use of Paracetamol for pain relief. You can resume normal activities progressively over the week and return to light duties at work at this time. However, strenuous activities should be avoided for a few more weeks.

Risks and complications

The removal of the gallbladder is generally a safe procedure, but like all operations, there are risks and complications associated with the procedure. Bleeding and infection are possible risks associated with this procedure. Other more significant risks are rare and include injury to the bile duct, leakage of bile fluid, accidental damage to the bowel and large blood vessels when surgical instruments are inserted through very small incisions and blood clots.

Advantages

The advantages of laparoscopic cholecystectomy when compared to open surgical technique include shorter hospital stay, smaller incisions, less post-operative pain and faster recovery.

However, if the procedure cannot be undertaken safely or the gall bladder is too severely inflamed and infected, conversion to an open operation with a longer cut may be required. This is uncommon and occurs in about 1% of patients. In this situation a longer period of recovery is necessary.

Conditions and Management