| Information
on gallstones
What are gallstones
Gallstones are crystals of cholesterol mixed with other elements like minerals
forming particles varying in size from sand or gravel to large marbles
present in the gallbladder.
Where is the gallbladder
The gallbladder is a small sac like structure approximately 10x 4 cms in size
attached to the under surface of the liver (Just under the right rib cage).
Why have I developed gallstones?
Bile is a mixture of cholesterol, salts and waste matter secreted by the
liver in a well balanced proportion. A change in this balance results in
super-saturation of cholesterol or other pigments or salts. This then results
in precipitation of small crystals which enlarge with time to form stones. They
are seen predominantly in the Western population possibly due to our diets.
About 1 in 3 women, and 1 in 6 men, form gallstones at some stage in their
life. They become more common with increasing age. The risk of forming
gallstones increases with pregnancy, obesity, and if you take certain
medicines.
Symptoms
& Signs of Gallbladder Disease
What symptoms will I need to look out for ?
Gallstones can present in various ways. The commonest being pain in the upper
abdomen going to the back. Some have a band like discomfort in the upper
abdomen. Some will experience a deep discomfort just under the breast bone.
Some patients have only a feeling of indigestion and bloating of the abdomen
on eating rich or cheesy or fatty foods. Quite often one has pain through out
the night that starts a few hours after their evening tea that presents like
a knot like discomfort under the right rib cage that refuses to shift. One
commonly hears female patients who have experienced labour pains before,
describing these attacks to be worse than labour pains. A few patients have
been admitted to the cardiac or coronary unit with a suspected heart attack
that proves to be gallbladder colic after investigations.
Complications
of Gallstone Disease
Can they be left alone or do I have to consider
treatment ?
Incidentally detected gallstones in patients who are not symptomatic may be
left alone. But if they are causing symptoms or presenting with complications
one has to consider treatment.
What are the complications ?
Acute Cholecystitis: Is the commonest complication, which is an inflammation
of the gallbladder. It presents with severe abdominal pain associated with
fever and sickness. The abdomen is very tender to touch and patients find
movement or any physical activity difficult. One has to take bed rest, plenty
of oral fluids and antibiotics which have a high concentration in bile to
treat this. Current recommendations based on the Cochrane review of all
studies suggest that an operation early in the acute phase gives good
results.
Patients who are malnourished, fragile with ill health from other causes,
diabetic patients and those on systemic steroids need to be careful as
cholecystitis in them can have higher risks.
Jaundice: if the stones migrate out from the
gallbladder into the bile duct they can obstruct the flow of bile from the
liver. This results in jaundice giving rise to a yellow skin, yellow
discolouration of the white of the eyes and dark urine. The offending stone
may pass into the bowel spontaneously, however one may need an endoscopic
procedure (ERCP) to remove these bile duct stones before treating those in
the gallbladder. In debilitated patients high levels of jaundice, fever and
sepsis (cholangitis) can have high risks. Pancreatitis: The bile duct and pancreatic ducts
have a common channel opening into the intestine (duodenum). Gallstones after
migrating from the gallbladder can be caught in this common channel and
result in obstruction of the bile and pancreatic ducts resulting in
pancreatitis. The pancreatic enzymes that are obstructed can result in severe
pancreatic inflammation which is sometimes life threatening. An endoscopic
procedure (ERCP) may be needed to clear these stones and open the lower end
of the ducts to prevent this happening again. Empyema / Perforation of Gallbadder: Empyema
(collection of pus) or perforation in a gangrenous gallbladder can sometime
occur if the inflammation is very severe in an obstructed gallbladder or if
the blood supply of the gallbladder is affected. The treatment is emergency
admission and drainage of the pus or operative removal of the gallbladder.
Other
Modalities for treating Gallstones
Can the stones be dissolved ?
This treatment works only if the gallbladder functions normally and the
stones are made purely of cholesterol. Both these factors are not usually
seen and stones that rarely dissolve on medical treatment are seen to appear
again. Shock wave treatment
This can be carried out for renal stones but for gallstones this therapy will
result in shattering of the larger stones into smaller particles which are
more dangerous as they could result in jaundice or pancreatitis after
migrating into the bile duct. This therapy is hence not routinely practiced.
Surgical
Treatment Options of Gallstones
Laparoscopic Cholecystectomy
This is the “gold standard” treatment for
gallbladder stones. Also called as “keyhole”, surgery. With the patient under
a full anaesthetic, tiny cuts are made on the abdominal wall and carbon
di-oxide gas is introduced under controlled pressure into the abdomen. With
long fine instruments and a telescope and camera relaying a picture on the
screen the surgeons operate within the abdominal cavity with a non- touch
technique. As there is no major incision or handling of the intra-abdominal
organs the recovery is swift and easy for the patient. Recovery after Laparoscopic Cholecystectomy
Most patients are having fluids 4-6 hours after
their operation and are mobile to use the toilet. They are given a light
supper that evening and mild pain killers. The following morning they are
ready to have a full breakfast and usually wish to go home with prescribed
mild analgesia. Day Case Laparoscopic Cholecystectomy
Some patients wish to have this operation as a “Day Case”. Young patients are
suitable for this approach where the patients go home the same evening after
a 6 hour recovery period in the hospital. They are given mild analgesics and
have a dedicated phone number to contact should they have any problem or wish
to discuss an issue of concern. Should however the operation be difficult or
complex the surgeon will elect to keep the patient overnight in hospital for
observation. Patients who do not like to stay in hospitals or
have young children at home express a strong wish to go home that evening.
One needs to have good support at home to be able to do this. Conversion to open operation
In 1-2 % of patients the laparoscopic procedure
has to be abandoned and a conventional incision is taken below the right rib
cage to remove the gallbladder. This may be necessary if the gallbladder is
very inflammed and adherent or if the anatomy is complex and not clear. The
patient may thereafter have a slightly prolonged recovery and may need to
stay in hospital for 3-4 days. One cannot predict this until the keyhole
operation is started. Intra-operative Cholangiography
Studies have shown that in 5-7% of patients there
are silent stones in the bile duct in addition to the stones in the
gallbladder. These stones are not evident on pre-operative imaging or
suspected based on liver function tests. They can remain in the bile duct and
produce symptoms later on in life. The only way to pick up these bile duct
stones is to carry out a procedure called cholangiography which entails
slipping a fine canula into the bile duct during the gallbladder operation
and injecting a radiological contrast and taking some pictures. Stones in the
bile duct will show up as tiny filling defects. This procedure adds another 5
-10 minutes to the operating time but is exceptionally useful and should be
routinely carried out.
Complications
related to Laparoscopic Cholecystectomy
There could be anaesthetic complications which
are related to the heart or lungs.
This is uncommon due to good intra-operative and
post-operative monitoring and advanced anaesthetic drugs. Wound infection related to the small cut from
which the gallbladder is removed can occur, but is rare. Injury to the bile
duct which is a narrow tube to which the gallbladder is attached can occur.
This may result in bile leakage. The incidence of this in literature is
0.2-0.4 %. Should this occur one may need an open operation. Carrying out an
intra-operative cholangiogram can help in detecting this injury early.
Stones in
the Bile duct In the majority of cases stones in the bile duct
are ones that have slipped there from the gallbladder. Rarely one can get
primary bile duct or intra-hepatic stones which are caused by biliary or
liver diseases.
What can one do to treat the bile duct stones
These stones can be removed during the same operation using special instruments
and catheters under screening or under direct vision using a telescope
(choledochoscope). The alternative option being an endoscopic approach
post-operatively called ERCP.
ERCP: (Endoscopic Retrograde Cholangio-Pancreaticography) This is an endoscopic procedure carried out under
sedation. The scope is passed through the mouth and passed down into the
duodenum which is the intestine beyond the stomach. The pancreatic and bile
ducts open here through a common channel. With a painless technique the lower
end of the bile duct is opened and the stones extracted with special
catheters. The procedure is often carried out as a day case and patients can
return home within 4-5 hours. If the stones cannot be extracted in one
sitting a small plastic tube may be left in the bile duct (stent) to be
extracted later. The complications can be bleeding from the small cut in the
intestine or pancreatitis.
EUS:
Endoscopic Ultrasound This advanced technology allows us to look at the
bile duct by carrying out an internal ultrasound scan. The ultrasound is
incorporated within the distal end of the scope. This procedure is safer than
an ERCP but can be used only to detect bile duct stones and not remove them.
One would have to do an ERCP thereafter to remove these stones. The EUS and
MRCP (magnetic resonance cholangio-pancreaticography) are both useful
diagnostic tools for detecting bile duct stones, however EUS has a higher
sensitivity especially when it comes to very tiny stones. EUS is also a day
case procedure carried out under sedation and patients can return home in 4-5
hours.
MRCP:
Magnetic Resonance cholangio-pancreaticography This radiological imaging modality is very useful
in outlining the anatomy of the bile duct and pancreatic ducts. It provides a
road map and helps the HPB surgeons to plan treatment. With the availability
of EUS and ERCP facilities in most tertiary level units in UK the use of MRCP
has decreased.
Results at the Surrey Gallstone clinic
The surgeon in this clinic is specialised in
biliary, pancreatic and gallstone disease and performs approximately 150-200
gallbladder operations a year. He has a open operation conversion rate of
0.75%. All patients will undergo an intra-operative cholangiography to ensure
there are no stones left behind in the bile duct. | 
