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 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. However, factors 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

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 most common symptom of gallstones is known as biliary colic, which is described as pain that:

• Intermittent pain 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.

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 to check for signs of infection.
• 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 – the gallbladder is removed through a large single incision approximately 12-18 cms long in the upper right hand side of the abdomen. A hospital stay of between 3-6 days can be expected and a return to normal activities in 4-6 weeks is usual. Since the advent of laparoscopic surgery this method is only used in people who are not suitable candidates for laparoscopic surgery due to the gallbladder being too severely inflamed and infected.

Open cholecystectomy is now uncommon and occurs in about 1% of cases.

Rarely 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

In this technique, the surgeon makes a number of small incisions (cuts) through the skin allowing access for a range of instruments. The gallbladder is removed through one of these small incisions. The recovery period is shorter and a hospital stay of 1 day is usual.

Conditions and Management

Investigative Procedures